电子病历疾病模板控制在病历质量管理中的作用

Control of Electronic Medical Record Templates in Medical Record Quality Management

目的探索通过对电子病历疾病模板的专业性和规范化的控制提高病历质量。方法对某综合性三甲医院的临床医生进行问卷调查。内容包括:调查对象对电子病历相关管理规范的认识,疾病模板的合理性及数量,使用疾病模板对提高工作效率、科研水平及改善病历质量等方面的作用。结果92.14%的人员认为使用电子病历模板后减少了病历书写时间,83.9%的人员认为使用模板后改善了病历书写质量,92.17%的人员认为使用模板对科研工作有利。另外仅有29.87%的调查对象了解电子病历模板的制作规范,了解程度较低。结论完善的电子病历疾病模板对提高工作效率、科研水平及改善病历质量具有重要作用。但在实际应用过程中仍存在不足,亟待解决。完善病历模板、加强质量监控可以提高电子病历质量及信息利用率。

Objective To explore methods to improve the quality of medical record quality management through control of electronic medical record templates. Methods A questionnaire was sent to the doctors of a comprehensive 3A hospital, covering the awareness of electronic medical records management practices, the reasonableness and number of the templates, the role of use the EMR template to improve the efficiency, the quality of medical records and the level of scientific research. Results 92.14% of them think EMR using template reduced the case file writing time, 83.9% of the people think that template improves the case file writing quality, and 92.17% of them think that template has advantages on the scientific research. Conclusion Perfect templates play a very important role in increasing efficiency, improving the scientific research level and medical quality. But in actual application process, there are still some shortages to be solved. Through improving the medical record templates, quality, control should be strengthened to improve electronic medical records and information quality utilization.