电子病历环节质控在医护文书质量控制中的应用

目的：探讨电子病历环节质控较纸质病历环节质控的优越性,以提高医护文书的质量。方法：统计我院2012年7~12月的住院病历数与纸质病历环节质控病历数的比值,分析环节质控点,并与2013年1~6月的住院病历数与电子病历环节质控病历数的比值及指控点对比。结果：2013年上半年环节质控病历比值、质控点增加、质控反馈时间下降较2012年下半年比较差异有统计学意义（P〈0.05）。结论：电子病历环节质控较纸质病历环节质控具有高效、全面、互动、及时的优点,促进了电子病历质量的提升。

Application of electronic medical record quality control in the quality control of medical instruments

Objective： To explore advantage of step-by-step management in electric medical records superior to paper medical records, improve doctors and nurses＇ records. Methods： Calculates the rate of quality of paper medical records by step-by-step management to medical records from July to December in 2012 and analyses spots of step-by-step management,compared with the rate and spots in electric medical records by step-by-step management from January to June in 2013. Results： The first half of 2013 the ratio of link quality control records,quality control points,quality control feedback time decreased with increase in the second half of 2012,the difference was statistically significant（ P 0. 05）. Conclusion： The advantages of high efficiency,overall,interdynamic factor and in-time compare electric medical records with paper medical records,which improve the quality of electric medical records.