电子病历对疾病分类工作的影响与改进  

作　　者：吕方[1] 刘春玲[1] 张丽[1] 王颖[1] 杜晓曦[1] 王肖然[1] 王玥[1] 

机构地区：[1]首都医科大学宣武医院,北京市100053

出　　处：《中国病案》2018年第8期43-45,共3页Chinese Medical Record

摘　　要：随着信息化、网络化的不断发展,电子病历已经替代纸质病历,成为了组成医院信息系统的关键部分。电子病历查阅简便快捷、信息传输速度快、格式内容规范;发现问题通过信息系统方便与临床医师沟通;编码员不用再翻阅纸质病案,提高了编码工作速度。但也存在了一些问题,例如:临床医师过度依赖电子模板,复制现成内容,严重影响病案质量,给编码工作带来不便;编码员依赖信息化系统,对信息自动编码不核对,导致错误。提高编码员的责任感;加强临床医师对病历重要性的认知;完善电子病历系统,加强系统质控。有助于提高编码工作的效率和质量。With the development of information and networking, Electronic medical records have replaced paper medical records, It has become the key part of hospital information system. Electronic medical records easy and quick to consult, information transmission speed, format content specification; Finding problems is easy to communicate with clinicians through information system; The staff don＇t need to read the paper medical records, and improves the speed of coding. But there are some problems, For example： Clinicians over-rely on electronic templates, replicating ready-made content, seriously affect the quality of medical records, inconvenience to coding;the Staff reliance on inibrmation systems, don＇t check for automatic coding of information, cause an erro. Enhance the responsibility of the staff; Strengthening clinicians understanding of the importance of medical records; Perfecting the Electronic Medical record system, strengthening system quality control. It is helpful to improve the efficiency and quality of coding work.

关 键 词：电子病历 疾病分类 质量控制 

分 类 号：R197.323[医药卫生—卫生事业管理]