18370份电子病案的缺陷分析

目的通过对电子病案质量的影响因素的分析,探讨提高病案质量的有效方法。方法参照卫生部《病案书写基本规范》和《住院病案质量评价标准》进行评分,对使用电子病案系统后6个月的终末病案进行病案质量监控及统计分析。结果在18,370份终末电子病案中,甲级病案18,003份,乙级病案367份,无丙级病案;手术科室的缺陷率明显高于非手术科室;病案缺陷中病程记录、复制粘贴及错字别字缺陷出现率占比例大。结论建立健全的电子病案管理制度及分明的奖惩制度,加强电子病案规范培训及医师法律意识,提高医院的病案管理水平。

Defects Analysis on 18370 EMR

Objective This paper discusses effective methods of improving medical records quality through analysis on affecting factors of EMR quality. Methods Analyzing the deficiency of electronic medical records by means of evaluating the scores of medical records according to Basic Norms of Medical Records and Medical Records Quality Evaluation Criteria. After 6 months application of EMR, medical records are having quality monitor and statistical analysis. Results In the 18370 medical records, 18003 medical records were evaluated as class - A and 367 records were evaluated as class - B; none of them were class - C ; the defects rate in surgery departments is obviously higher than non-surgery departments; the defects rate of course record, copy and paste, and wrongly written and mispronounced characters accounts for high parts. Conclusions It suggests establishing perfect EMR management system and clear reward and punishment system, strengthening standard training of EMR and physicians＇ legal consciousness and improv- ing management level of medical records in hospital.