摘要
目的探索电子病案质量管理的有效方法,提高电子病案质量。方法分析电子病历书写中出现的问题,指出容易产生医疗纠纷的原因。结果针对电子病案在医疗纠纷诉讼中的重要作用,提出在电子病案的书写过程中要做到真实、及时的反映医疗行为,从而减少医疗纠纷的发生。同时还应在技术层面对电子病案加强监管。结论加强电子病案质控管理是减少医疗纠纷的重要因素。
Objective To investigate the effective methods for quality management of electronic medical record in order to improve its quality. Methods The problems existed in the writing of electronic medical record were analyzed to indicate the reasons contributing to medical disputes. Results on basis of the importance of electronic medical record in medical dispute lawsuit,medical behaviors should be truly and timely reflected in the writing of electronic medical record to reduce medical disputes,in addition,monitor for electronic medical record should also be enhanced on the technique level. Conclusion Strengthening the quality control of electronic medical record is a dominate factor to reduce medical disputes.
出处
《中国病案》
2010年第9期11-12,共2页
Chinese Medical Record
基金
桂林医学院教学科研立项课题青年专项基金(2009C16)资助
关键词
电子病案
医疗纠纷
监管
electronic medical record
medical dispute
monitor
