摘要
目的规范病案首页的填写,提高电子病历质量。方法对我院病案首页填写存在的问题进行总结分析,提出改进措施。结果通过对病案首页书写存在的问题及时反馈和整改,为规范医疗文书书写起到了促进作用。结论加强病历首页正确书写,是提高电子病历质量的重要环节。
Objective To improve the quality of electronic medical record by filling in the first page of the electronic medical record standardly. Methods The causes of the defects in the first page of electronic medical records were analyzed and pointed out that the reasons for medical dispute prone. Result The significance of strengthening the supervision of the first page of electronic medical records must be stressed to explore the technical and management level, including implementing strict supervision, strengthening training. Conclusion Strengthening the quality control in the first page is a dominate factor and to improve the quality of electronic medical record.
出处
《临床医学工程》
2011年第3期463-464,共2页
Clinical Medicine & Engineering
关键词
首页
书写
电子病历
First pag
Writing
Electronic medical record
