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对休养员疗养进行记录的电子病案进行网上检查和归档后的随机抽查发现存在过分依赖复制、粘贴和拷贝,书写不及时、时间不准确,打印归档不及时等问题。主要原因是医务人员责任心不强,法律意识淡漠,质控力度不够。采取针对性措施:强化责任意识,完善病案管理制度,加强法律法规意识,完善电子病案监控功能,才能提高电子病案的质量。
The electronic medical records recorded for the recuperation of infirmary cases were randomly checked after they were inspected online and archived. They found that there was over-reliance on copying, pasting and copying, improper writing, inaccurate time, and improper printing and archiving. The main reason is the medical staff’s sense of responsibility is not strong, indifferent legal awareness, quality control is not enough. To take targeted measures: to strengthen the sense of responsibility, improve the medical record management system, strengthen the awareness of laws and regulations, improve the monitoring of electronic medical records in order to improve the quality of electronic medical records.