社区卫生服务中电子病历质量控制体系及其应用效果的研究

Establishment of Electronic Medical Record Quality Control System in Community Health Care and Its Applying Efficiency

目的探索适用于社区卫生服务工作的电子病历质量控制体系,并通过实际应用验证该体系在提高和规范社区卫生服务电子病历质量方面的效果。方法以前期社区卫生网络系统为基础,建立社区卫生服务电子病历质量控制体系,对北京市东城区从事社区卫生服务工作的全科医生按质量控制体系进行管理,并比较2006年下半年～2008年上半年电子病历质量的变化。结果电子病历的优秀率从25.55%提高至32.48%,差异有统计学意义(χ2=10.677,P=0.001);合格率从86.19%提高至96.62%,差异有统计学意义(χ2=50.050,P=0.000)。结论电子病历质量控制体系的应用可以提高社区卫生服务医疗质量,规范社区诊疗行为。

Objective To explore a quality control system of electronic medical record(EMR)suitable for community health service(CHS),and to examine its effect in improving and standardizing EMR through practical application.Methods An EMR quality control system was set up based on the existing CHS net system,by which general practitioner management in CHS institutions of Dongcheng District of Beijing were conducted.The changes of EMR quality from the second half year of 2006 to the first half year of 2008 were compare...