摘要
当前护理病历的书写以全新的信息技术应用为依托,实现了信息化和高效化的管理,为有效防止医患纠纷提供了重要依据。但在此背景之下也对护理电子病历的书写质量、书写规范提出了更为严格的要求。随着书写质量问题的日益凸显,该文以根本原因法对护理电子病历书写质量展开调查,通过质量控制小组建立进行资料收集分类,并完成影响质量原因的查找,同时提出相关控制策略,以规范电子病历书写,实现其质量的提升。从而为医院的病例建设夯实基础,也为减少医患纠纷提供可靠依据。
At present,the writing of nursing medical record relies on the application of brand-new information technology,which realizes the informationization and high efficiency management,and provides an important basis for effectively preventing doctor-patient disputes.But in this context,it also puts forward more strict requirements for the writing quality of nursing electronic medical record,book writing standard.With the increasingly prominent writing quality problems,this paper investigates the writing quality of nursing electronic medical record with the Root Cause Analysis,collects and classifies the data through the establishment of quality control group,finds out the causes affecting the quality,and puts forward relevant control strategies to standardize the writing of electronic medical record and improve its quality,so as to lay a solid foundation for the case construction of the hospital and provide a reliable basis for reducing doctor-patient disputes.
作者
李峰林
陈银评
LI Fenglin;CHEN Yinping(Information Center,Zhongshan Hospital Affiliated to Xiamen University,Xiamen,Fujian Province,361002 China)
出处
《科技资讯》
2021年第33期190-192,共3页
Science & Technology Information
关键词
根本原因分析法
医患纠纷
电子病例
质量缺陷
质量控制
Root cause analysis
Medical disputes
Electronic case
Quality defect
Quality Control
作者简介
李峰林(1983-),男,本科,高级工程师,研究方向为医疗信息化;通信作者:陈银评(1980-),男,本科,高级工程师,研究方向为医疗信息化,E-mail:lfljf153@126.com。
