无纸化对病案质量及护理工作的影响

The Effect of Paperless on the Quality of Medical Records and Nursing Work

摘要: 病案管理是医院管理的重要组成部分。长期以来，纸张作为病案的唯一载体，给医院的管理工作带来诸多问题，如纸质病案存在着占用空间、信息共享差、支出大、不易保存等缺点。无纸化电子病案是病案不再以纸质形式存在、流动、保持和使用，而是全部通过计算机处理和保存，其具有诸多纸质病案无法实现的优势。随着医院发展及信息技术的进步，无纸化电子病案是医院信息化建设的必然趋势，这将彻底改变医院病案管理的模式，能有效降低医院管理成本、提升管理效率，病案共享能力的提升也将为分级诊疗及远程诊疗提供有力支持。本文通过无纸化电子病案在医院的实际应用，分析了其在病案归档率、数据统计、提高病案质量、实现数据共享、改善复印、提高病案书写质量、改变护理工作模式及提高护理质量等方面的优势，体现了无纸化电子病案在提升医院管理效率、实现区域一体化建设中的重大意义。随着国家卫生事业的发展，医疗信息技术的提高，无纸化电子病案将全面替代纸质病案，成为病案在管理工作中的主要形式。

Abstract: Medical record man-agement is an important part of hospital management. For a long time, paper, as the only carrier of medical records, has brought many problems to hospital management, such as paper medical rec-ords occupy space, poor information sharing, high expenditure, not easy to save and other short-comings. Paperless electronic medical record means that medical records no longer exist, flow, maintain and use in the form of paper, but are all processed and preserved by computer, which has many advantages that paper medical records cannot achieve. With the development of hospital and the progress of information technology, paperless electronic medical record is the inevitable trend of hospital information construction, which will completely change the mode of hospital medical record management, effectively reduce the cost of hospital management, improve the efficiency of management, and the improvement of the ability of medical record sharing will also provide strong support for hierarchical diagnosis and treatment and remote diagnosis and treatment. Based on the practical application of paperless electronic medical record in hospitals, this paper analyzes its ad-vantages in medical record filing rate, data statistics, improving the quality of medical record, real-izing data sharing, improving photocopying, improving the quality of medical record writing, changing the mode of nursing and improving the quality of nursing. It reflects the great significance of paperless electronic medical record in improving hospital management efficiency and realizing regional integration construction. With the development of national health service and the im-provement of medical information technology, paperless electronic medical record will completely replace paper medical record and become the main form of medical record management.