Implementation of Paperless Medical Records of Obstetric Department
By introducing a maternity hospital to sort out the constraints of paperless management of obstetric medical records and develop a targeted system to achieve the process of paperless management of obstetric medical records,this article discusses the advantages of paperless management and the resulting management system adjustments and risk control issues.In order to solve the problems of low paper filing rate and uneven filing quality in obstetric medical records,achieve homogenization management,sort out the key issues that restrict the paperless management of obstetric medical records,and solve them through online review of fetal heart monitoring reports,electronic signature of informed consent forms between doctors and patients to generate PDF files,import outpatient reports and related business system documents into the paperless management system,so as to achieve paperless archiving of obstetric medical records,improve quality and efficiency,and standardize the diagnosis and treatment process.After paperless management,it is necessary to strengthen risk control and continuously optimize the management model.Precise demand analysis,continuous system testing and optimization,and training for all staff can improve the applicability of the system,enhance clinical acceptance,and have reference significance for hospitals undergoing transformation of medical record filing mode.
Obstetrics departmentPaperlessElectronic medical recordsMedical informatization