电子运行病历质量控制分析

Study on quality control in management of electronic medical records

目的探讨电子运行病历的质量管理.方法计算机在线随机抽取电子病历664份为计算机组,同时抽取住院病房电子病历250份为病房组,对比2组电子运行病历质量,并总结计算机组电子运行病历缺陷.结果2组电子运行病历甲级率差异无统计学意义(P>0.05);电子运行病历缺陷中,入院记录现病史不全46.7%,一般情况缺陷18.3%,日常病程记录缺陷12.3%.结论应加强电子病历实时监控,提高质量控制工作效率.

Objective To discuss the quality control in managing electronic medical records.Methods A total of 664 electronic medical records were selected though online system as computer group.Another 250 electronic medical records of in-patients were selected manually as ward group.The defects in electronic medical records were summarized and compared between 2 groups..Results There was no significant difference in rate of class A record between two groups.Main defects found was insufficient of medical history(46.7%),insufficient of general data(18.3%)and insufficient of progress note(12.3%).Conclusion it is necessary to strengthen the supervision in quality control of electronic medical records.