电子病历内涵质量影响因素与控制策略  

Influencing factors and control strategies of electronic medical record connotative quality

作　　者：刘伟[1] 

机构地区：[1]天津市南开医院病案科,天津300100

出　　处：《中国城乡企业卫生》2017年第7期150-152,共3页Chinese Journal of Urban and Rural Enterprise Hygiene

摘　　要：电子病历内涵质量是电子病历的核心,是医疗质量管理的难点,也是电子病历能否在临床医疗决策中发挥作用和优势的关键。电子病历内涵质量包括临床诊断、诊断依据、病情分析和治疗效果四方面内容。电子病历内涵质量水平受制于医师综合专业素质、医务人员医事法律素养与法制观念、科室的严格管理与上级医师的严格把关等因素。提高电子病历内涵质量,应从建立电子病历分类管理制度、强化重点病历管理、建立病历质量分级管理与负责制、完善电子病历质量控制的各项制度、建立电子病历书写能力,考核与准入制度以及正确处理电子病历内涵质量、医疗服务质量和医护工作质量的关系等方面着手。Electronic medical record connotative quality is the core of electronic medical record,it is the difficulty of medical quality management,and the key to whether electronic medical records can play a role and advantage in clinical medical decision-making. Electronic medical record connotative quality includes four aspects of clinical diagnosis,diagnosis basis,disease analysis and treatment effect. The connotative quality level of electronic medical records is limited by the factors such as comprehensive professional quality of physicians,the medical legal literacy and legal concept of medical staff,strict management of departments and strict supervision of higher doctors. To improve the quality of the electronic medical record connotation,we should begin with establishing the classified management system of electronic medical records,strengthening the management of key medical records,establishing the medical record quality management and responsibility system,improve the quality control system of electronic medical records,establishing examination and access system for electronic medical record writing ability and correctly handling the relationship between the electronic medical records connotation quality,medical service quality and medical work quality.

关 键 词：电子病历 内涵质量 影响因素 

分 类 号：R197.323[医药卫生—卫生事业管理]