电子病历在临床康复应用中的问题及干预对策  

Problems and Intervention Countermeasures of Electronic Medical Record in Clinical Rehabilitation

作　　者：荀芳[1,2,3] XUN Fang(Department of Graduate,Institute of Scientific and Technological Information of China,Beijing 100038,China;Department of Information Research,Institute of Rehabilitation Information,China Rehabilitation Research Center,Beijing 100068,China;Department of Information Research,Institute of Rehabilitation Information,China Rehabilitation Science Institute,Beijing 100068,China)

机构地区：[1]中国科学技术信息研究所研究生部,北京100038 [2]中国康复研究中心康复信息研究所信息研究室,北京100068 [3]中国康复科学所康复信息研究所信息研究室,北京100068

出　　处：《中国卫生标准管理》2022年第15期10-13,共4页China Health Standard Management

基　　金：中央级公益性科研院所基本科研业务费专项资金资助项目(2022CZ-10)。

摘　　要：近年来随着临床技术的发展与经验的积累,临床康复治疗干预及相关措施的要求也不断提升,而病历作为临床诊治及检查等医疗过程的有效记录方式,其在临床康复治疗及干预中的作用及意义均较高。电子病历作为取代手写病历的病历方式,其在临床康复应用中的问题仍普遍存在,包括病历录入、病历内容把控、病历的安全性、存储与监管、医务人员应用态度及行为等方面的问题,同时针对康复患者较为特殊的情况,存在病历设计与应用方面的不足,故应针对上述问题进行针对性防控与干预措施的制定,从电子病历整个流程的各个阶段针对性干预,并针对康复患者的临床诊治及检查特点进行细节的完善,以实现提高临床康复相关电子病历质量的目的,为临床康复效率的提升提供有效条件,并为电子病历在临床康复中的应用提供参考依据。The requirements of clinical rehabilitation intervention and related measures were increasing with the development of clinical technology and the accumulation of experience in recent years, while the medical record was an effective recording record of clinical diagnosis, treatment and examination during the medical process, its role and significance in clinical rehabilitation treatment and intervention were high. The electronic medical record as a way to replace handwritten medical record, it still had some common problems in clinical rehabilitation, including medical record entry, medical record content control, medical record safety, storage and supervision,doctors’ application attitude and behavior, etc. there were some deficiencies in the design and application of medical records for the special situation of rehabilitated patients, so targeted prevention and control and intervention measures should be formulated for the above problems, the targeted intervention should be carried on according to each stage of the whole process of electronic medical record, at the same time, the details should be refined according to the clinical diagnosis, treatment and examination characteristics of rehabilitation patients, in order to improve the quality of clinical rehabilitation related electronic medical records, provide effective conditions for the improvement of clinical rehabilitation efficiency,and provide reference basis for the application of electronic medical records in clinical rehabilitation.

关 键 词：电子病历 临床康复 干预对策 个性化诊疗 康复效率 针对性干预 

分 类 号：R197[医药卫生—卫生事业管理]