电子病历实时质量控制研究

目的：评价电子病历实时质量控制模式对降低在架病历缺陷率的控制效果。方法：以2002年国家卫生部制定的《病历书写规范》对病历时限性、完整性要求为理论依据，采用专家咨询法形成病历实时质量控制模式的指标及实现方法，在医院原结构化电子病历的基础上二次开发。以随机抽样的方法对实验前后828份在架病历进行统计分析。结果：编制了病历首页、入院记录、首次病程记录、日常病程记录、上级医师查房记录、转科（转入科与转出科）记录、阶段小结、手术前讨论记录、手术记录、术后首次病程记录、出院记录、死亡记录、入院医患谈话记录13项记录，在时限、完整性、逻辑关系三个纬度进行控制。实验组干预前、后在架病历零缺陷率由32.21%提升到59.22%，其中时限性缺陷率由22.6%下降到12.14%，完整性缺陷由干预前的34.13%下降到干预后的17%。结论：病历实时质量控制模式可以提高在架病历的质量，特别是降低时限性缺陷与完整性完陷。

Study on Real-time Quality Control of Electronic Medical Records

Objective：To evaluate the real-time quality control effectiveness to reduce defects of medical electronic record by quality control panel of secondary development. Methods： To make the secondary development on basis of the hospital original structured electronic medical record according to the norms on completeness and time limit of medical records formulated by the Ministry of health of China. The Real-time indicators of quality control model and its implementation technique were decided by expert advice. 828 electronic medical records sampled randomly were analyzed statistically before and after experiment. Results：13 electronic medical records （ homepage, admitted records, the first course record, daily course records, senior physicians rounds records, section transfer record, stage summary, operation discussion record, operation record, the first course record after operation, discharged record, and death record, and communication record） were controlled in recording time, integrity, and logic relationship. The zero defect rate of electronic medical records on the ward spot was up from 32.21% to 59.22% after intervention. Time defect rate was down from 22.6%to 12.14%and integrity defect rate down from 34.13%to17%after intervention. Conclusion：The real time quality control of electronic medical record enables physicians to improve the quality of electronic medical records of ward spot, especially time and integrity defects.