Challenges faced by medical record paper in the era of electronic medical records

In the era of electronic medical records, medical record paper, as a traditional way of recording medical information, faces various challenges. This article discusses the challenges of paper medical records in the era of electronic medical records, and explores how to balance tradition with new technology.

With the rapid development of information technology, more and more medical institutions choose to use electronic medical record system to record and manage patients' medical information. Electronic medical records have the characteristics of digitization, convenience and sharing, which greatly improve the work efficiency of doctors and the quality of medical services. However, there are still some medical institutions using traditional medical record paper. Here are the main challenges paper medical records face in the era of electronic medical records:

1. Data entry speed and accuracy: Compared with the fast data entry and automation functions of the electronic medical record system, handwritten medical records require doctors and nurses to spend more time writing and organizing information, and are prone to scribbled or wrong writing. Condition. This will increase the workload of medical staff and reduce the accuracy and reliability of data.

2. Difficulties in inter-institutional data exchange: In traditional medical records paper, patients' medical information is usually stored in paper form in the hospital archives, which cannot be instantly shared and transmitted across institutions. This presents certain difficulties for multiple visits or medical services in emergencies, which may lead to loss or delay of information.

3. Privacy and security protection: Medical records are vulnerable to access and tampering by unauthorized personnel, and there are risks of information leakage and privacy violations. In contrast, electronic medical record systems are able to take more security measures to protect patients' privacy and data security.

In the face of these challenges, we should find a balance between tradition and new technology:

1. Promote the standardization and standardization of medical record paper: improve the efficiency and accuracy of data entry by formulating a unified medical record paper format and content requirements. Medical institutions can develop training programs to ensure that medical staff use and fill out medical record papers correctly.

2. Promote the popularization and application of the electronic medical record system: medical institutions can actively invest in and promote the electronic medical record system, provide training and technical support, and encourage medical staff to gradually switch to digital medical information recording.

3. Connection between medical record paper and electronic medical record system: During the transition period, medical institutions can explore the combination of medical record paper and electronic medical record system to achieve data interoperability. For example, by scanning paper documents and converting them into electronic files for easy archiving and sharing.

In conclusion, medical record paper is facing challenges in the era of electronic medical records, but it still has certain importance and use value. We should find a balance between traditional medical record paper and new technologies, and gradually promote digital medical information management to improve the efficiency and quality of medical services.