甲型HIN1流感电子病历与手写病历规范化比较  

Comparison of Normalization between Electronic Medical Records and Handwritten Medical Records of Type A H1N1 Influenza Cases

作　　者：单晶[1] 孔明[1] 仇丽霞[1] 张薇[1] 孟艳英[1] 李宁[1] 

机构地区：[1]首都医科大学附属北京佑安医院,北京市100069

出　　处：《中国病案》2010年第6期45-46,共2页Chinese Medical Record

摘　　要：目的比较我院点选式电子病历与手写病历在甲型H1N1流感住院患者临床应用中的规范性差别。方法选我院甲型H1N1流感住院患者手写病历117份、电子病历127份。对甲型H1N1流感常见症状如发热、咳嗽等进行统计,分析两者病案规范性差别。结果电子病历与手写病历在症状、体征的描述记录上有显著性差异。结论点选式电子病历较传统手写病历对甲型H1N1流感住院患者病史收集记录更加全面、规范。医生应加强规范化收集病史的意识。Objective To compare normalization differences between point-and-click electronic medical records and handwritten medical records in clinical application of type A H1N1 influenza cases in our hospital.Methods 117 handwritten medical records and 127 electronic medical records of inpatients admitted to our hospital with type A H1N1 influenza were selected.Statistical analysis was done on the common symptoms of type A H1N1 influenza,such as fever,cough,to compare normalization differences above two medical records.Results There were significant differences in descriptions of symptoms and signs in electronic medical records and handwritten medical records.Conclusion The point-and-click electronic medical records have a more comprehensive and correct records in history collection of inpatients with type A H1N1 influenza compared with traditional handwritten medical records,indicating that clinicians should further improve awareness of standardized history collection.

关 键 词：电子病历 点选式 手写病历 病案 规范化 甲型HIN1流感 

分 类 号：R511.7[医药卫生—内科学]