病历书写时限性问题管理浅析

Analysis of the Writing Time Limit Management of Medical Records

目的加强病历书写时限质控,提高病案质量。方法利用电子病历质控系统,对2013年7月至2013年9月入院记录和首次病程记录的书写时限进行检查。结果经过三个月连续检查、反馈、培训、落实扣罚措施,病历书写及时率持续提高。7-9月份首次病程记录的按时完成率分别为95.4%、98%、98.6%;7月-9月份入院记录按时完成率分别为95.7%、96.4%、96.7%。结论应用电子病历质控系统监控病历完成时间,有效地促进了病案质量的提高。

objective To strengthen the management of medical records time limit quality control and improve the quality of medical records. Methods Using electronic medical record quality control system, to monitor the writing time of resident admit note and the first time progress note from July to September in 2013. Results Timely completion rates of the first time progress note in July, August and September are 95.4% ,98% ,98.6% ; Timely completion rates of resident admit note in July, August and September are 95.7% ,96.4% , 96.7%. After three months of continuous inspection,feedback,training, the implementation of punishment measures, medical record writing timely rate has improved. Conclusion Using electronic medical record quality control system to monitor the accomplish time of medical record can promote the improvement of the quality of medical records.