电子病案在临床实施中的影响调查

Impact Survey of Electronic Medical Record in Clinical Implementation

目的了解电子病案系统在临床应用后对病历书写的快捷性、方便性和病案的安全性及内涵质量的影响。方法采用现场观察和问卷调查的方法对临床医师进行电子病案实施前后对比调查,并采用病案个案评价方法对电子归档病案进行内涵质量评价。结果实施电子病案系统后,入院记录和首次病程记录书写时间分别平均缩短了16.1分钟和11.9分钟;编辑、审查病案和书写医嘱较实施前更方便(P<0.01),然而电子病案查房、签名等方面不方便;容易出现病历未及时签名、被篡改、拷贝,医嘱开错等安全隐患。结论电子病案系统在临床应用中更快捷、更方便,容易出现一些质量问题和安全隐患,因此当前有必要研发出新的质量监测体系,促成电子病案对医疗质量的提高作用。

Objective To understand the influence on the fast,convenient,safZety and the connotation quality of medical record in the clinical application.Methods Comparatively investigating electronic medical record before and after implementation by participant observation and questionnaire survey.Evaluate connotation quality by case evaluation method.Results Writing time of hospital records and the first course record were respectively reduced 16.1 minutes and 11.9 minutes after implement electronic medical record system.Editing,reviewing and writing doctor＇s advice were more convenient than before（P0.01）.But ward round of doctor and signatures were less convenient.Easy to have potential safety hazard such us not in time signature,tampered,copy,error doctor＇s advice.Conclusion Electronic medical record system can be faster,more convenient in the clinical application,but also easy to have some quality issues and potential safety hazard.So it is necessary to develop new quality monitoring system to improve the medical quality.