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目的分析近一年我院全面实施电子病历系统后的部分住院电子病历存在的问题,探讨其的改进措施。方法随机抽取2011年7月-2012年6月的住院电子病历3000份,三位检查员检查选取的电子病历资料的质量,并填写调查表,分析电子病历中存在的问题。主要问题:(1)电子记录的拷贝和粘贴,(2)过度使用的电子模版,(3)缺少的患者或医师的签名,(4)记录的时间不准确,(5)未及时记录,以及(6)其他。按电子病历缺陷成因分为以下四组:医师、护士、患者或亲属以及一般工作人员例如基本信息记录员和病案编码员。结果六类主要问题中,抽取的电子病历缺陷率分别占16.5%,27.8%,9.2%,3.9%,2.7%和5.5%。不同的成因组内记录缺陷率也明显不同。电子病历的使用权限对其缺陷率也有一定的影响。结论在电子病历的生成过程中,各组人员都应该认真按照工作要求尽职尽责,电子病历系统可以针对专业性人员进行使用权限管理、修改权限管理、专业性模版设计以方便使用并减少错误。建立电子病历管理系统应包括完善的系统管理应用程序、上级医师审阅并签署电子病历、有关电子病历书写法律和法规的培训,电子病历评审流程的确立,不断的完善电子病历的制度建设和网络建设。 相似文献
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目的:利用电子病历应用水平分级评价标准对全国部分医院的电子病历系统进行评价,了解我国电子病历系统应用水平的不平衡性。方法:通过方差分析、一般线性模型等方法比较不同地域医院得分和评级的差异。结果:通过单因素分析发现东部医院的电子病历系统应用水平高于中部和西部,中部医院和西部医院之间差异没有统计学意义。电子病历系统功能应用水平的高低可能和医院规模、服务量、医院类型、级别等因素有关,在纳入了这些因素的多因素分析中,地域对电子病历系统功能应用水平的影响仍有意义。结论:东部电子病历系统的发展水平高于中部和西部,这种差距可能会进一步加大我国医疗服务的地域不均衡性,因此需要给予进一步关注。 相似文献
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病历书写是口腔医师临床实习中的重要的环节,我院口腔医学本科生实习过程中在带教老师的指导下使用电子病历系统,本文通过问卷调查分析本科生在实习时电子病历的使用情况,通过抽查分析电子病历的质量,认为电子病历能够指导实习生提升临床各方面能力,但存在着对模板病历依赖,未能充分调动临床思维能力等不足,提出通过加强岗前教育,调动学生主观能动性等解决方法,为医学教育者教学及科研提供借鉴。 相似文献
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目的研究电子病历质量监控信息反馈系统的构建及应用价值。方法根据医院目前使用的“军卫一号”工程系统的功能以及日常工作中的问题,结合病历质控的特点,经过多次广泛的搜集材料和征求临床一线医护人员的意见构建电子病历质量管理监控信息反馈系统。结果通过加强病历质量的实时监控,缩短了病历中问题反馈到临床的时间,减少了中间环节,开通了临床医师与质控专家在线对话功能,提高了病历质控信息反馈的速度,提升了监控效果,促进了医院医护质量的提高,在使用过程中收到较好的效果。结论电子病历质量监控信息反馈系统的应用有利于提高病历质量,值得推广和应用。 相似文献
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随着《电子病历系统功能规范》和《电子病历系统功能应用水平分级评价方法及标准》等规范的发布,越来越多的医院使用了电子病历系统,但大部分医院只局限于使用住院电子病历,门诊电子病历还在沿用手写的传统模式。基于门诊电子病历系统在某三甲医院上线的过程为背景,介绍了门诊电子病历特点,以及门诊电子病历帮助门诊医生解决的模板病历书写等一些实际问题。最后对新一代门诊电子病历系统提出一些新颖的病历自动形成等功能点,门诊电子病历的应用需要尽量符合门诊医生思维习惯,贴近门诊医生看诊过程,起到对门诊医生的辅助指导作用,为门诊电子病历系统的建设和应用提供指导。 相似文献
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目的 探讨病历书写质量问题产生原因,寻求改善方法以提升病历书写整体质量。方法 于2020年8月3日-2020年8月14日期间,使用分层抽样和方便抽样法,选取某心血管病医院的40名医师为调查对象进行问卷调查和深度访谈,共收集40份调查问卷及访谈记录。使用平均值、频数和百分比对变量进行描述,采用F检验比较不同病区间的工作量差异。结果 平均每个病区一线医师有8人,进修医师或研究生3人。心内科医师平均每份入院记录需38分钟,心外科医师需33分钟,内科重症病房需62分钟,不同类型病区间有明显差异,P<0.05。85%的医师认为当前电子病历的质量问题主要为错填和漏填,其中71%的医师认为错填是由于手动输入错误,62%的医师认为不能实时更新的患者信息容易漏填。58%的医师认为病历质量问题产生的根本原因是医师病历书写工作量大,心内科医师每日平均病历书写工作耗时4小时,占医师工作量的50%;其余病区医师每日2小时,占工作量的25%,病区间有显著性差异,P<0.05。40%的医师认为系统可用性会影响书写效率。结论 从临床医师的角度出发,病历书写质量问题的根本原因是记录工作量大,结合临床医师实际... 相似文献
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The aim of the study was to use psychological theory to identify and evaluate factors influencing clinical autopsy requests. A series of pilot interviews were conducted with 20 clinicians to identify beliefs about the benefits and drawbacks, social groups and circumstances influential in the decision to make an autopsy request. The most common beliefs, together with measures of intention to request autopsies, were incorporated into a questionnaire which was distributed among all appropriate clinicians in four hospitals. Statistical analyses identified which beliefs had the most influence on clinicians'' intentions to request autopsies. A total of 145 clinicians returned the questionnaire, a response rate of 42%. Clinicians were significantly more likely to request autopsy the more they thought that the outcome of requesting would be of educational value, would confirm clinical diagnoses, would not distress relatives, would not be time-consuming and that the request itself would receive support from their consultant. An autopsy request was unlikely in circumstances where clinicians felt uncomfortable when requesting relatives'' permission and when the patients were elderly. The fear of causing distress to relatives and the degree of support from the clinician''s consultant were found to be the strongest predictors of intention to request autopsies. These are two areas in which intervention could help to increase autopsy request rates. 相似文献
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Objective
This work seeks to complement and extend prior work by using a multidisciplinary approach to explain electronic medical records (EMR) system use and consequent performance (here, patient satisfaction) among physicians during early stages of the implementation of an EMR.Design
This was a quantitative study, with data obtained from three distinct sources: individual-level and social-network data from employees; use data from EMR system logs; and patient satisfaction data from patients and/or authorized decision-makers. Responses were obtained from 151 physicians and 8440 patient satisfaction surveys over the course of a 1-year period at the shakedown phase of an EMR system implementation.Results
Physicians who were better connected, both directly and indirectly, to their peers—that is, other physicians—for advice on their work, used the system less than those who were less connected. In addition to such social network ties, demographic characteristics (gender and age), three personality characteristics (openness to experience, agreeableness and extroversion) and a key technology perception (perceived usefulness) predicted EMR system use.Conclusions
For hospital administrators and other stakeholders, understanding the contributors to, and the relative importance of, various factors in explaining EMR system use, and its impact on patient satisfaction is of great importance. The factors identified in this work that influence a physician''s use of EMR systems can be used to develop interventions and applications that can increase physician buy-in and use of EMR systems. 相似文献13.
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以技术接受模型和任务技术匹配理论的整合模型为基础,引入任务技术匹配、感知有用性、感知易用性和使用意愿4个变量,构建研究模型,分析影响医务人员使用慢性病管理信息系统的因素.研究结果表明任务技术匹配、感知有用性、感知易用性均对使用意愿产生正向影响. 相似文献
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基于解释水平理论、隐私计算理论和计划行为理论构建在线医疗平台用户隐私披露行为影响因素模型,运用问卷调查方法对模型进行实证检验.结果表明感知风险负向影响用户远期披露意愿,对近期披露意愿无显著影响;感知收益对远期披露意愿和近期披露意愿均产生正向影响等. 相似文献
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Jeffrey L. Schnipper Jeffrey A. Linder Matvey B. Palchuk Jonathan S. Einbinder Qi Li Anatoly Postilnik Blackford Middleton 《J Am Med Inform Assoc》2008,15(4):513-523
Clinical decision support systems (CDSS) integrated within Electronic Medical Records (EMR) hold the promise of improving healthcare quality. To date the effectiveness of CDSS has been less than expected, especially concerning the ambulatory management of chronic diseases. This is due, in part, to the fact that clinicians do not use CDSS fully. Barriers to clinicians'' use of CDSS have included lack of integration into workflow, software usability issues, and relevance of the content to the patient at hand. At Partners HealthCare, we are developing “Smart Forms” to facilitate documentation-based clinical decision support. Rather than being interruptive in nature, the Smart Form enables writing a multi-problem visit note while capturing coded information and providing sophisticated decision support in the form of tailored recommendations for care. The current version of the Smart Form is designed around two chronic diseases: coronary artery disease and diabetes mellitus. The Smart Form has potential to improve the care of patients with both acute and chronic conditions. 相似文献
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基于UTAUT模型,融合安全因素与隐私因素构建医疗美容APP用户采纳行为模型,进行问卷调查和结构方程验证,结果表明医疗美容APP用户期望绩效与努力期望受社会因素影响,用户实际使用行为受便利条件与使用意愿直接影响,同时受期望绩效、努力期望、社会影响、安全风险与隐私风险间接影响。 相似文献