电子病历书写时限质控体会

目的加强病历书写时限质控,提高病案质量,保障医疗安全。方法利用电子病历系统,对2012年1-12月份10595份运行病历的入院记录、首次病程记录、医嘱、手术记录的书写时限进行监控。结果经过一年多以来持续不断地周周检查、通报、整改、反馈,并落实奖惩措施,使病历书写及时率从56.25%提高到93.2%,明显改善。结论利用电子病历系统可以有效地监控病历完成时间,从而加强病历质量的环节管理,提高病历质量。

Experience of Time Limit Quality Control in the Written of Electronic Medical Record

Objective To strengthen the time limit quality control of the written of medical record, improve the quality of medical record and ensure the safety of medical treatment. Method With the help of electronic medical record system, monitoring the resident admit note, the first course of the disease, medical orders and the written time limit of operation recording of 10595 cases of running medical records from January to December in 2012. Result By continuous inspection weekly, report, rectify and reform, feedback as well as put reward and punishment into effect, the timeliness ratio was increases from 56.25% to 93.2% and improved obviously. Conclusion With the application of electronic medical record system, the finish time of medical record can be monitored effectively, thus strengthen the link management of medical record and improve its quality.