摘要
电子病案是保存、管理、传输和重现的数字化的病人医疗记录,它作为重要的医疗和法律文书,发挥着越来越重要的作用。电子病案应用中存在的责任心不强、签名不全、业务水平低下、法律意识淡薄等问题,因此需要采取加强医生的三基培训、建立奖罚制度、转变服务理念措施,提高病历书写质量,保障患者安全。
Electronic medical record is a digitalization medical record of storage,management,transportation and recurrence,which play more and more important role as vital medical and law document.The problems during electronic application are that lack of responsibilities,incomplete signature,low professional level and weak law consciousness.Therefore,this article suggests that should strengthen three basic training of doctor,setting up reward and punishment system and changing service idea for medical record writing quality improvement and patient safety guarantee.
出处
《中国病案》
2011年第3期46-46,共1页
Chinese Medical Record
关键词
电子病案
问题
对策
Electronic medical record
Problem
Countermeasure
