电子病历在医疗质量控制管理中的应用与研究  

Application and research of electronic medical record in medical quality control management

作　　者：宋雪君[1] Song Xuejun(Computer Center of Fujian Maternal and Child Health Hospital,Fuzhou 350001,China)

机构地区：[1]福建省妇幼保健院计算机中心,福州350001

出　　处：《现代计算机》2023年第6期88-90,共3页Modern Computer

摘　　要：数字化医疗是当代医疗卫生健康领域的重要发展方向,电子病历系统取代手写纸张病历用于记录、存储、传输和管理数字化的病人医疗记录,提高了医护人员的工作效率,提高了病历书写质量。通过对电子病历的研究,深入讨论电子病历在病历质控管理、护理质控管理、病案质控管理、院感质控管理等方面的应用,并介绍了电子病历在医疗质量管理中的两个应用实例,最后讨论了电子病历未来的研究方向。Digital medical treatment is an important development direction in the field of contemporary health care.Electronic medical record system replaces handwritten paper medical records for recording,storing,transmitting and managing digital patient medical records,which improves the working efficiency of medical personnel and improves the quality of medical records.Through the research on electronic medical record,the application of electronic medical record in medical record quality control management,nursing quality control management,medical record quality control management,hospital sense quality control management,etc.was discussed in-depth,and two application examples of electronic medical record in medical quality management were introduced.Finally,the future research direction of electronic medical record was discussed.

关 键 词：电子病历 质控管理 结构化 HL7 

分 类 号：R197.323[医药卫生—卫生事业管理]