电子病历模式下神经内科病历书写的探讨  

Medical Records Writing for Residents in Neurology Department Under the Model of EMR

作　　者：米荷音[1] 胡文立[1] MI Heyin;HU Wenli(Neurology Department,Beijing Chaoyang Hospital,Beijing 100020,China)

机构地区：[1]北京朝阳医院神经内科,北京100020

出　　处：《中国继续医学教育》2019年第12期51-54,共4页China Continuing Medical Education

摘　　要：电子病历的普遍运行给临床医师病历书写带来便利,但同时也存在弊端,本文讨论了朝阳医院神经内科在电子病历模式下,根据疾病性质、严重程度等分别建立不同类型标准化模板,并且在标准化模板中根据神经内科疾病特点设立多选项,充分发挥电子病历的优势,通过增加电子病历考核及师资培训培养等手段,达到锻炼住院医师病历书写与临床思维能力及培养优秀带教老师的目的。Common operation of electronic medical record for clinical physicians,medical record writing bring convenience,but also has disadvantages at the same time,This article discussed the Neurology Department of Chaoyang Hospital how to make use of advantages and avoid disadvantages,give full play to the advantages of electronic medical records,training exercise resident medical record writing and clinical thinking ability.

关 键 词：电子病历 住院医师 规范化培训 病历 模板 师资培训 

分 类 号：G642[文化科学—高等教育学]