电子病案系统对医院病案质控工作的促进与挑战  

The Promotion and Challenges of Electronic Medical Record Systems in Hospital Medical Record Quality Control

作　　者：徐一楠 胡晓星[1] Xu Yinan;Hu Xiaoxing(Medical Administration Department,Beijing Chaoyang Hospital,Capital Medical University,Beijing 100020,China)

机构地区：[1]首都医科大学附属北京朝阳医院医务处,北京100020

出　　处：《中国病案》2025年第1期4-6,共3页Chinese Medical Record

摘　　要：信息技术发展中的电子病案系统作为现代医疗行业的关键组成部分,对医院病案质控工作具有深远影响。本文通过研究电子病案系统在医疗质量控制中的应用,重点分析电子病案系统的信息共享效率、病案质量控制、安全性和隐私保护等方面,同时探讨了在应用过程中遇到的主要挑战,如信息过度暴露、电子病历内容质量优劣不均、质量控制薄弱等问题。电子病案系统通过提高病案准确性和完整性、优化病案审核流程、加强信息安全措施等方面显著提升了病案质控水平。然而,也存在着信息安全隐患、电子病案个体化不足等问题,需要通过加强系统的质量控制和优化操作流程加以解决。电子病案系统对提升医院病案质控工作具有积极作用,同时也面临新的挑战。医院需要加强电子病案系统的质量控制措施,优化用户操作流程,持续完善系统功能,确保医疗服务安全和高效,为医疗服务质量的持续改进提供可靠支持。The electronic medical record system, as a key component of the modern healthcare industry, has a profound impact on the quality control of hospital records. This article studies the application of electronic medical record systems in medical quality control, focusing on analyzing information sharing efficiency, medical record quality control, security and privacy protection of electronic medical record systems. It also discusses the main challenges encountered in the application process, such as excessive information exposure, uneven quality of electronic medical record content, and weak quality control. The electronic medical record system significantly improves the level of record quality control by improving the accuracy and completeness of records, optimizing the review process, and strengthening information security measures. However, there are also security risks and insufficient individualization of electronic medical records, which need to be solved by strengthening the quality control of the system and optimizing the operation process. The electronic medical record system has a positive impact on improving the quality control of hospital records, but also faces new challenges. Hospitals need to strengthen the quality control measures of the electronic medical record system, optimize the user operation process,continuously improve the system functions, and ensure safe and efficient medical services to provide reliable support for the continuous improvement of medical service quality.

关 键 词：电子病案系统 医疗质量控制 病历管理 

分 类 号：R197.323[医药卫生—卫生事业管理]