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目的比较我院点选式电子病历与手写病历在甲型H1N1流感住院患者临床应用中的规范性差别。方法选我院甲型H1N1流感住院患者手写病历117份、电子病历127份。对甲型H1N1流感常见症状如发热、咳嗽等进行统计,分析两者病案规范性差别。结果电子病历与手写病历在症状、体征的描述记录上有显著性差异。结论点选式电子病历较传统手写病历对甲型H1N1流感住院患者病史收集记录更加全面、规范。医生应加强规范化收集病史的意识。
Objective To compare the normative differences in the clinical application of point-by-point electronic medical records and handwritten medical records in hospitalized patients with influenza A (H1N1). Method selected hospital H1N1 flu patient handwritten medical record of 117, electronic medical records of 127. Common symptoms of influenza A (H1N1) such as fever, cough and other statistics, analysis of the difference between the two cases of medical records. Results Electronic medical records and handwritten medical records in the description of symptoms and signs of significant differences. Conclusion The selective electronic medical record is more comprehensive and standardized than the traditional handwritten record in the history of inpatients with influenza A (H1N1). Doctors should strengthen the awareness of standardized medical history.