电子病历内涵质量实时监控应用研究.pdf

中文摘要 的病历内涵质量高于住院医师。通过采用网络监控、现场检查、技能培训 等措施，能够降低病历未按时归档率和格式错误率，而使甲级病案率升高， 病历内涵质量得以提升；②影响电子病历内涵质量的因素主要包括医师综 合素质能力、医务人员对新医改的认识程度、病历重视程度以及上级医师 是否严格把关4方面；③稳步提升电子病历内涵质量的具体措施包括：加 强环节质量监控，定期开展技能培训，培养医务人员法律意识，实行病历 分类管理，建立病历书写准入制，实施科级三级质控和院级五级质控，全 院讲评与适度扣罚并举。 关键词：电子病历；内涵质量；实时监控；技能培训；研究 英文摘要 MedicalRecords ResearchofElectronic Applied Real·-time Connotation Quality Monitoring ABSTRACT recordsarethematerialandculturalassetsofthe Objective：Medical medical recordthetrackof andresearch institutions，which medicine，teaching and arethecollectivewisdomthehardwork development，and ofallthemedical thenervousmedical personnel．Especiallyagainst environmentofthe recordsarethe doctor-patientrelationship，medical forthetreatmentofmedical to evidence important dispute．Howstrengthen an ofmedicalrecordshasbeen of qualitymanagement importantsubject administrators．Thisisto the controlmethod hospital studyinvestigatequality suchaSnetwork thefield andskills and monitoring．takinginspection training SO thereal—time of medical torealize electronic on，and monitoring records，SO to oft