电子病历是信息技术和网络技术在医疗护理领域应用的必然产物,是用电子设备保存、管理、传输的数字化患者医疗记录。在计算机专业人员的指导配合下,2009年11月我院率先在乳腺甲状腺外科实行电子病历试点,将护士从繁忙、重复的工作中解脱出来,实行了网络共享,但在使用过程中电子护理文件也存在一定缺陷与不足,为此我们进行原因分析并提出管理对策。现报告如下。 EHR is a necessary product of the application of information technology and network technology in the field of medical care. It is a digital patient medical record saved, managed and transmitted by electronic equipment. In cooperation with the guidance of computer professionals, in November 2009, our hospital took the lead in the implementation of electronic medical records in breast thyroid surgery pilot, the nurses from busy, repetitive work freed, the implementation of the network sharing, but in the process of electronic care documents There are also some shortcomings and deficiencies, for which reason we analyze and propose management strategies. The report is as follows.