环节质控对电子病历质量的影响

目的 探讨电子病历环节质控对病案质量的影响。方法 随机抽取2012 年7 月到2012 年12 月终末病案6200 份和2013 年1 月至2013 年6 月通过网络环节质控电子运行病历6200 份，并追踪经环节质控后的终末病历质量。按照卫生部制定的《病历书写基本规范》对终末病案进行检查评估，针对病案质量、实时性缺陷、书写缺陷等数据进行统计分析。结果 2013年1 月-6 月较2012 年7 月-12 月病案甲级率升高4.46%（P ＜0.01），乙级率下降4.43%（P ＜0.01），丙级率由0.03%降为0%；实时性缺陷率明显下降，书写缺陷较前下降。结论 电子病历环节质控减少病历缺陷的发生，有效提高终末病案质量。

Effect of Step-by-step Management in Electric Medical Records Quality Control

Objective To explore the importance of step-by-step management in electric medical records＇ quality control. Methods To extract randomly 6200 terminal medical records in 2012 July to December, to extract 6200 medical records in 2013 January to June after step-by-step management, then estimates electric terminal medical records by basic criterion of medical records writing and gets statistics analysis of medical records qualified, time defects and writing defects. Results The first half year in 2013 contrasting with second half year in 2012, the rate of grade A medical records raises 4.46%（ P〈0.01）,the rate of grade B medical records drops 4.43% （ P 〈0.01）, grade C medical records are eliminated; time defects decrease notably, defects decrease. Conclusions Step-by-step management in electric medical records decreases medical records defects, improves effectively the quality of electric terminal medical records.