论文部分内容阅读
为更好地规范医师书写电子病历，我们将近年来在国际医院评价中出现的一种体现以患者为中心的追踪方法学理论及方法引入到电子病历质量持续改进管理中，结合具体案例，运用个案追踪和系统追踪的方法评判诊疗过程中存在的问题，制定持续改进方案，并建立长效管理机制，以减少缺陷病历发生，从而提高病案甲级率，促进医疗质量的提高，确保医疗安全。“,”To regulate the physicians' nar atives of electronic medical records bet er, we applied the patient oriented tracer methodology theory which emerged in international hospital appraisal in cur ent years to establish a Long-term management mechanism for quality management of electronic medical records. We judged existing problems in the process of evaluation of diagnosis and treatment on the basis of individual case and tracking system with specific cases. And then keep continuous improvement to reduce the defects of cases, Improve the medical grade rate, the quality of medical and guarantee safety of medical.