基于临床医师视角探讨电子病历系统的问题及改进思路  

Discussion on the Problems and Improvement Ideas of Electronic Medical Record System from the Perspective of Clinicians

作　　者：季劼[1] 吴文健 唐俊伟 巨桓宇 于子溢 Ji Jie;Wu Wenjian;Tang Junwei;Ju Huanyu;Yu Ziyi(Department of General Surgery,The First Affiliated Hospital of Nanjing Medical University,Nanjing 210029,Jiangsu Province,China;不详)

机构地区：[1]南京医科大学第一附属医院普外科,江苏省南京市210029 [2]徐州医科大学附属医院病案统计科,江苏省徐州市221004 [3]南京医科大学第一附属医院检验科,江苏省南京市210029

出　　处：《中国病案》2022年第10期34-36,共3页Chinese Medical Record

摘　　要：电子病历系统的推广和使用,极大地提高了医务人员书写病历的效率,能在促进病历规范化书写的同时提高医院的病历质量,提升病历的研究和利用价值。病历书写质量是医疗质量和医疗安全的重要体现,然而在医院信息化建设不断完善的背景下,某院以电子病历为基础平台的病案管理工作依然存在不足。作为病案的书写者,临床医师更应积极主动思辨病案管理工作的重要性及其发展方向。基于临床一线青年医师视角,结合日常工作现状及所思所想,分析该院病案书写过程中存在的问题,从软件智能化、平台开放化、管理扁平化、病案无纸化等四个方面来思考该院新时代电子病历管理改进对策,浅析病案管理发展的前景。The popularization and use of electronic medical record system has greatly improved the efficiency of medical staff in writing medical record,which can promote the standardized writing of medical record and improve the quality of medical record in hospital,and enhance the research and utilization value of medical record.The quality of medical record writing is an important reflection of medical quality and medical safety.However,under the background of the continuous improvement of hospital information construction,the medical record management based on the electronic medical record platform in a hospital still has shortcomings.As the writer of medical record,clinicians should actively think about the importance and development direction of medical record management.Based on clinical perspective a line of young physicians,combined with the daily work status and thoughts,analyzes the existing problems in the process of the hospital medical record writing,from the intelligent software,platform,open,flat management,paperless record and so on four aspects to think about its new era electronic medical records management improvement countermeasures,analyzed the prospect of the development of medical record management.

关 键 词：病案管理 智能化 病案无纸化 电子病历 

分 类 号：R197.323[医药卫生—卫生事业管理]