On the one hand, it needs various management means and rules and regulations to guarantee it; On the other hand, it is necessary to combine all kinds of new technologies, integrate all kinds of resources through feasible technical channels, clearly implement the responsibility to specific individuals, improve the hospital's ability to manage the quality of medical records, and effectively remind and urge medical staff to complete medical records on time and with good quality through pre-control means such as statistics, analysis, early warning and three-level quality evaluation. Improve the first-class rate of medical records, thus improving the comprehensive competitiveness of hospitals.
Second, save time.
For doctors, they have to treat many patients every day, and 70% of their work every day is spent on handwritten medical records. Through various standardized templates and auxiliary tools provided by the electronic medical record system, medical staff can not only be freed from tedious and repetitive medical record writing, but also concentrate on diagnosis and treatment of patients, and the medical records written by templates are more complete and standardized. At the same time, doctors can spend more time to improve their professional level and treat more patients, thus improving the economic benefits and medical level of hospitals.
Third, the quality of medical records.
By providing a complete, authoritative, standardized and rigorous medical record template, the electronic medical record system can avoid common problems such as scribbling, missing pages, missing items and vague and irregular terms, improve the qualified rate of medical record review and improve the comprehensive competitiveness of hospital services.
Fourth, improve the burden of proof.
Medical records are legally effective medical records, which provide legal documentary evidence of medical behavior facts for medical accident identification and medical disputes. If there is a legal dispute and the unwritten content is regarded as no inquiry and inspection, then the court will regard it as negligence, which will cause great passivity and even losses to the hospital. Through standardized medical records, problems such as semantic ambiguity, scribbling, missing pages and items are avoided, and possible avoidable mistakes that may adversely affect all aspects of the hospital are reduced, which provides a strong legal basis for the inversion of the burden of proof. It not only protects the legitimate rights and interests of hospitals and medical staff, but also brings benefits to the reputation and economic benefits of hospitals.
Fifth, stabilize the source of the disease
Electronic medical record system provides patients with long-term health records, supports rapid retrieval of health records, provides more historical reference materials for medical staff to make decisions, and improves patients' recognition of hospitals.
Sixth, improve the medical records.
The content of paper medical records is free text, which may be illegible, incomplete and ambiguous. Replication is prone to potential errors. It can only be passively used as a reference for doctors to make decisions, and it is impossible to realize active reminders, warnings or suggestions. The phenomenon of alteration is prominent, the medical records are written casually, and the computer printed medical records are not copied properly, which leads to the phenomenon of "arrogance", the content of a medical record is missing, and the medical records are not filled in in time. Cao Chun electronic medical record system fundamentally solved the above problems.
Seven, provide first-hand valuable information
In medical statistics and scientific research, it is difficult to screen typical medical records and retrieve statistical data. Through the electronic medical record system, we can not only quickly retrieve all kinds of medical records we need, but also make the previously laborious medical statistics very simple and fast, providing first-hand information for scientific research and teaching.