黄旭

[摘要] 目的 对计算机打印病历的常见问题进行整理并分析，制定相应解决策略，提高计算机打印病历整体质量。 方法 搜集我院2011年12月~2013年12月部分计算机打印病历，共950份，依据《病历书写基本规范》的原则对病历进行整理，结果汇总，查找常见问题原因及制定相应对策。 结果 950份病历中共有406份存在问题，主要集中在病历书写不规范282份，病历记录不完整208份，病历复制错误192份，病历记录不准确150份，并制定相应改进对策。 结论 计算机打印病历是病案管理的发展趋势，合理应用计算机，认真负责填写病历，将大大方便临床工作。

[关键词] 计算机；病历；病案管理；提高对策

[中图分类号] R197.3   [文献标识码] B   [文章编号] 2095-0616（2014）08-155-03

Analysis and countermeasures of common problems of computer-printed medical records

HUANG Xu

Information Center, Third Affiliated Hospital of Liaoning Medical College, Jinzhou 121000, China

[Abstract] Objective To clear up and analyze the common problems of computer-printed medical records,develop corresponding solving strategies, and improve the overall quality of computer-printed medical records. Methods A total of 950 copies of computer-printed medical records of our hospital from December 2011 to December 2013 were collected and cleared up based on the principles of "Essential Requirements of Medical Records Writing". Then the results were summarized, causes of common problems were sought out and corresponding measures were developed. Results Of the 950 copies of medical records, 406 copies had problems, including 282 copies of unstandardized medical records writing, 208 copies of incomplete medical records, 192 copies of medical records replication mistakes, and 150 copies of inaccurate medical records. Corresponding improving countermeasures were developed. Conclusion Computer-printed medical records are a development trend of medical records management. Rational application of computers and serious and responsible medical records writing will largely facilitate clinical work.

[Key words] Computer; Medical records; Medical records management; Improving countermeasures

病历作为临床诊疗过程中重要的数据记录，在临床诊疗、卫生监督管理、疾病预防与控制和医疗保健等方面具有非常重要的作用。随着医疗案例的增加，临床诊疗数据更加种类繁多、形式变化多样、关联程度高，数据量也越来越多，医疗信息的分析和再利用也显得比较费时费力，因此建立有效挂历庞大医疗的数据系统显得尤为重要。电子病历（electronic medical record，EMR）是保存、管理、传输和重现的数字化及现代化的医疗记录系统，取代手写纸张病历，以电子化方式实现病历信息集采集、存储、传输、处理和利用的综合管理，在需要时可以最大限度地得到详细、准确、全面的相关信息[1]。本文通过对950份电子病历进行整理，发现406份病历存在不同问题，并加以分析，制定相应策略，以最大化完善我院计算机打印病历现状，避免不必要的医疗风险，现将结果总结如下。……