摘要
目的探讨护理电子病历应用的缺陷与干预对策。方法随机抽查200份出院病历,根据病历书写规范的标准及电子病历管理要求,分析应用过程中出现的缺陷。结果护士对电子病历的应用程序、汉字输入不熟悉;无严格实行分级授权制度;法制观念淡薄;护理记录无突出重点有复制粘贴现象;病历质控缺乏力度、质控标准缺乏严谨性。结论强化电子病历相关知识培训,加强病历安全系统管理及监督,实行病历全程质控,是减少应用缺陷和提高病历质量的有效方法。
Objective To explore the defaults and the relative measures of applying electronic nursing case history. Methods 200 cases were selected randomly from the outpatients. Analyze the defaults that have eccured during the course of using electronic nursing case history according to the criterion of writing case history. Results It＇s found that nurses wereunfamiliar to the using of electronic case history and the input of chinese words.Furthermore,the grade system was not strict;the legal idea was not enough;the nursing records had no points and the phenomenon of copy case history was too often;the power of control the case history＇s quality was weaken. Conclusion Strenghten the fraining and the supervising are the effective method to reduce the defaults of case history and to improve the quality of it.
关键词
电子病历
缺陷
干预对策
Electronic history
Default
Relativemeasures
