电子病历应用中常见问题与对策  

Common Problems and Countermeasures in the Application of Electronic Medical Record

作　　者：刘爱军[1] 王韬[1] Liu Aijun;Wang Tao(Information Center,Beijing Tiantan Hospital,Capital Medical University,Beijing 100160,China)

机构地区：[1]首都医科大学附属北京天坛医院信息中心,北京市100160

出　　处：《中国病案》2020年第10期51-52,共2页Chinese Medical Record

摘　　要：通过对目前电子病历使用过程的主要问题进行归纳,包括有拷贝病历出现内容雷同和原则性错误;登录电子病历系统不是账户拥有者本人;上级医师审阅病历不及时;电子病历功能未充分开发和利用。针对这些问题,采取技术措施以建立电子病历的自检功能,利用智能技术有条件地允许电子病历内容复制和粘贴;建立特殊人员的登录账户,实习医师和进修医师使用自己的账户登录;积极开发电子病历的功能,为临床诊疗决策提供支持。同时制定电子病历管理规定,对修改、查询和拷贝做出具体要求,杜绝电子病历在使用过程中出现低级错误,从而提高电子病历书写质量。After nearly 20 years of development,the electronic medical record system in China has been relatively mature in technology,but there are still some problems affecting the quality of electronic medical record in use.This paper analyzes the common problems existing in the use of electronic medical records,such as the content copy and paste,the review and signature of superior doctors are not timely,and other common problems affecting the quality of electronic medical records,and discusses the solutions.This paper puts forward some suggestions,such as using intelligent technology to permit copying and pasting the contents of electronic medical records conditionally,reminding the contents of previous modifications when the same place of electronic medical records is repeatedly modified,and improving the accuracy and efficiency of ward rounds and consultation records of superior doctors.The application of intelligent technology is beneficial to improve the quality of electronic medical records.

关 键 词：电子病历 智能技术 语音识别 书写质量 

分 类 号：R197.323[医药卫生—卫生事业管理]