实行电子病历对病案质量的影响分析

目的:选取实行电子病历前后两年的病案资料,通过统计学分析,评价实行电子病历后病案质量的变化。方法:根据《广东省病历书写基本规范》对4年间的病案进行评价,应用SPSS13.0,通过t检验和秩和检验,对实行电子病历前后的病案缺陷率和甲级病案率进行比较。结果:实行电子病历前后两年各科室的病案缺陷率和甲级病案率差值有统计学意义。结论:实行电子病历后,该院的病案质量总体上得到改善。

Analysis of implementation of electronic medical records on record quality

Objective The medical record information in two years before and after the implementation of electronic medical records was extracted.The changes of medical record quality after the implementation of electronic medical record were evaluated by statistical analysis.Method The quality of medical records in four years was evaluated according to the "basic norms of medical writing,Guangdong Province".The defect rate and rate of Class A medical records in two years before and after the implementation of electronic medical records were compared by the T test and rank sum test in the application SPSS 13.0.Results The differences of defect rate and rate of Class A medical records of clinical department in two years before and after the implementation of electronic medical records from October 2008,are statistically significant.Conclusion The implementation of electronic medical records improves the overall quality of medical record.