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结构化电子病历作为医改的重要内容,正在全国范围内积极推广。本文从实地考察慎重选择、专人负责分工合作等5个方面阐述了我院结构化电子病历的实施策略,并介绍了该项目实施后方便医师工作,提高病案质量等功能,探讨了实施结构化电子病历的经验,提出了对于实施过程的建议。
Structured electronic medical records, as an important part of medical reform, is being actively promoted across the country. This article elaborates the implementation tactics of structured electronic medical record in our hospital from five aspects such as the careful choice of fieldwork, the specialization of division of labor and so on. It also introduces the functions of facilitating the physician’s work and improving the medical record quality after the implementation of the project, Experience in medical records, put forward suggestions for the implementation process.