随着信息技术的发展,电子病案以其快捷、方便、信息共享等优点,完全代替了传统的手写病历。但是,由于认识和管理上的疏漏,电子病案的书写存在着不少的问题,有的甚至造成了严重的后果。笔者对某医院1700多份电子病案进行了查阅审核,现就如何提高电子病案的书写质量和管理水平,有 With the development of information technology, electronic medical record completely replaces the traditional handwritten medical records with its advantages of quickness, convenience and information sharing. However, owing to the omission of knowledge and management, there are many problems in the writing of electronic medical records, and some of them even have serious consequences. I conducted a review of more than 1,700 electronic medical records in a hospital, and on how to improve the writing quality and management of electronic medical records, there are