电子病案在院长查房中的应用  

Application of Electronic Medical Record in the President Ward-rounds

作　　者：靖艳菊[1] 李恬[1] 

机构地区：[1]首都医科大学附属北京天坛医院,北京市100050

出　　处：《中国病案》2013年第5期50-51,共2页Chinese Medical Record

摘　　要：为了使院长查房达到更好的效果,将电子病案系统应用于院长查房。查房前根据查房的内容准备需要的病案号和医疗数据,查房采取现场显示病案,院领导和各科室主任共同评价和讨论的形式,查房的内容主要是通过病案了解医疗过程中存在的问题和病案质量。将电子病案应用于院长查房可以使院长了解日常的工作状态;现场解决问题,尤其是涉及多个部门的问题;通过对医疗数据的展示和分析,使科室了解自己的医疗运行状况;为院领导与科室主任建立了一个交流沟通的平台等。从而实现促进临床医疗质量,提高管理水平的目的。In order to achieve better results, we use the electronic medical record system in the hospital president ward-rounds. We prepare the medical records number and medical data before ward-rounds, hospital leadership and department director evaluate and discuss case of illness through electronic medical record. The contents of ward-round are the medical problems that exist in the process and quality of medical record. The application of electronic medical record in hospital president ward-round can make hospital president understand daily work status, solve problems at current, especially the problems involving multiple departments. Departments understand the medical conditions themselves and set up a communicate platform for hospital leadership and department director through the presentation and analysis of medical data. These methods can promote clinical medical quality, improve the management level.

关 键 词：电子病案 院长查房 实施 优势 

分 类 号：R197.3[医药卫生—卫生事业管理]