电子病历系统与手工书写病历的效率对比研究

Difference in Efficiency Between Computer-based and Handwritten Records

为探讨电子病历系统书写入院记录和出院记录的效率,将40位职称同为中级的医生随机分成2组,分别使用电子病历系统方法与传统手工方法书写入院记录和出院记录,全过程实时记录完成入院记录和出院记录各部分的时间。将医生完成入院记录和出院记录的时间换算为速度分数,专家对病历的评分记为质量分数,二者加权后得到综合分数,并对两种方法进行统计分析。结果显示,在书写入院记录的对比研究中,电子病历系统方法组平均总用时为15.02 min,手工书写方法组为43.10min,电子病历系统方法组在完成质量方面总得分高于手工书写方法组,电子病历系统方法组在综合效率方面平均得分高于手工书写方法组,其差异具有统计学意义(P<0.01)。在书写出院记录的对比研究中,电子病历系统方法组平均总用时为4.34min,手工书写方法组为33.32min,电子病历系统方法组在完成质量方面总得分高于手工书写方法组,电子病历系统方法组在综合效率方面平均得分高于手工书写方法组,其差异具有统计学意义(P<0.01)。由此可以看出,电子病历系统能够有效提高书写病历的速度和质量,大大减轻医生书写病历的工作量,书写病历的效率明显优于手工方法。

To explore the efficiency of writing admissions records and the leaving hospital records with the electronic medical record system, 40 doctors with the intermediate of a technical post were randomized into 2 groups and wrote admissions records and leaving hospital records respectively with the electronic system and by hand, the traditional method. The time for completing each part of the records was noted down in real time across the entire process. The time taken by the doctors to complete the records was changed into marks of speed, the assessments of the records by experts were changed into marks of quality, and composite marks resulted from the two after weighting. Statistical testing was done with the two methods. Results： To research into writing admissions records, the average total time taken by the electronic and traditional groups was respectively 15.02rain and 43.10 min. In terms of quality, the electronic group got higher marks in the overall score. In terms of general efficiency, the electronic group got higher marks in the average score. The difference was statistically significant （P〈0.01）. To research into writing the leaving hospital records, the average total time taken by the electronic and traditional groups was respectively 4.34min and 33.32min. In terms of quality, the electronic group got higher marks in the over-all score. In terms of general efficiency, the electronic group got higher marks in the average score. The difference was statistically significant （P〈0,01）. Conclusion： Using the electronic medical record system can effectively improve the speed and quality of writing the medical history, greatly reduce the work volume of doctors, and bring about much greater efficiency than the traditional method.