电子病历应用现状分析与改进措施

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。

Analysis on the Application Status of Electronic Medical Records and Improvement Countermeasures

Objective To analyze problems existing in some hospitalized electronic medical records after the application of electron- ic medical record system last one year and investigate improvment countermeasures. Method 3000 cases of hospitalized electronic med-ical records from July 2011 to June 2012 were selected randomly in our hospital, three inspectors examined the quality of them, then filling examination tables, analyzed problems existing in the electronic medical records. The mainly existing＇problems were： 1） the copy and paste of electronic records, 2） overuse of electronic masterplated, 3） lack of the signatures of the doctors, 4） inaccurate record time, 5） without recording timely and 6）others. The electronic medical records were divided into four groups according to de- fects： doctors, nurses, patients or relatives and general workers such as recorders of basic information or medical records coders. Re- sult The defect rate of the six kinds of problems were respectively 16.5%, 27.8%, 9.2%, 3.9%, 2.7% and 5.5%. The intra- group recording defects rate of different causes were also not the same. The permission of the electronic medical records also had influ- ence on the defect rate. Condusion In the generative process of the electronic medical records, workers of all the groups should fulfill their trust carefully. The electronic medical record system should design to decrease the mistakes by permission management, modifi- cation authority management and professional masterplate design. The establishment of medical record management system should conclude thorough system management application program, superior doctors approve and sign the medical records, the training of writting laws of electronic medical records and the establishment of assessment process, thus to improve the institutional and network establishment of electronic medical record continuously.