摘要
机打病案是指应用文字处理软件编辑生成并打印的病案,是电子病案的前奏,它超越传统病案的模式,提高了病案书写的效率且字迹清晰,但它强大的复制功能及安全性等问题,给病案管理带来新的挑战。机打病案常见问题如反复复制、模板设计不规范、机打与手写混合现象等等。应建立机打病案相关制度,对进行机打病案的人员提出准入要求,并实施多层次、多环节的病案质量监控。
Computer-printing medical records refers to medical records apply Word software to edit the content. It is a prelude of electronic medical records, which exceed traditional pattern of medical records. It improves writing efficiency, having clear writing as well. However, it powerful copy function and safety problems bring new challenges to medical records management. The computer-printing medical records include copy repeated, substandard pattern design, combination of computer-printing and handwriting. We should establish related system about computer-printing medical records and propose access requirement for computer-printing medical records personnel, carrying out multi-level, multi-segment of medical records quality monitoring.
出处
《中国病案》
2010年第11期16-17,共2页
Chinese Medical Record
关键词
计算机
病案
问题
对策
computer
medical records
problems
countermeasures
