网络实时监控电子运行病历质量的效果评价

目的对网络实时监控电子运行病历的效果进行评价。方法以卫生部《病历书写基本规范》为标准，对某大型三甲综合医院实施网络实时监控前后的电子运行病历质量进行统计分析。结果电子运行病历在一定程度上存在不同缺陷，实施网络实时监控后，电子运行病历的质量有明显改变，其中病历合格率、72小时三级医师查房记录缺失发生率、入院记录缺失发生率的改变等共10项差异有统计学意义（P〈0．005）。结论网络实时监控提高了电子运行病历的合格率，减少了电子运行病历中存在的各类缺陷。

The Evaluation of the Effect of Real-time Monitoring and Controlling the Quality of Electronic Medical Records Running on the Network

Objective To evaluate the effects of online real-time monitoring and controlling the electronic medical records.Methods In accordance with the Fundamental Standard of Writing Medical Records issued by the Ministry of Public Health,a statistical analysis is carried out on the quality of the electronic medical records before and after adopting online real-time monitoring and controlling in a large high rank general hospital.Results To some extent,various faults exist in electronic medical records running on the network,nevertheless,after applying online real-time monitoring and controlling,the quality of the electronic medical records is obviously improved.The differences in 10 items are of statistical significance(p<0.005,such as the percent of pass of the medical records,the incidence of incomplete 72h three-level wards checking records,the incidence of incomplete inpatient admissions records,etc.,).Conclusion The implementation of online real-time monitoring and controlling has improved the ratio of quality of the electronic medical records running on the network and decreased a range of defects exist in them.