电子医嘱系统对医嘱书写规范的影响  

The Effect of Electronic Medical Order System to Writing Standard of Medical Records

作　　者：伍姗姗[1] 杨旭丽[1] 刘钰[1] 黄祖凤[1] 吴玮斌[1] 

机构地区：[1]南昌大学第一附属医院,南昌市330006

出　　处：《中国病案》2012年第1期36-37,共2页Chinese Medical Record

摘　　要：目的了解电子医嘱系统对医嘱书写规范的影响。方法按医嘱单书写规范标准,随机抽取2010年1月至10月1150份归档病案进行检查,其中试点电子医嘱病案461份,手写医嘱病案698份。结果电子医嘱单缺陷率35.8%;比手写医嘱单缺陷率低12.6%,减少或避免了手写医嘱的缺陷如药名书写不统一、缩写不规范、涂改、书写格式不规范和药品剂量不写等,但医嘱漏手工签名成为电子医嘱的主要问题。结论电子医嘱在书写质量、规范性方面优于手写医嘱,亟待电子签名的合法化,以解决签名问题。Objectives to know about the effect of electronic medical order system to writing standard of medical records.Methods According to writing standard of medical order,it randomly selects 1150 filing medical records from January to October 2010 for inspection,in which there are 461 medical records of pilot electronic orders,698 medical records of handwriting medical records.Results The defects rate of electronic medical order is 35.8% that is lower 12.6% than handwriting medical order which reduces or avoid defects of handwriting medical order like non-unity medicine name,non-standard abbreviation,mending,non-standard writing mode and lack of drug doze and etc.However,the main problem of electronic medical order is lack of handwriting signature.Conclusions The writing quality and standardization of electronic medical order are better than handwriting medical order,which need legalization of electronic signature for solving signature problem.

关 键 词：电子医嘱 手写医嘱 书写规范 影响 

分 类 号：R197.324[医药卫生—卫生事业管理]