环节质控对电子病历质量影响的效果分析

Effect Analysis of Step-by-step Quality Control to Electric Medical Records' Quality

目的探讨环节质控及质控结果的奖罚对电子病历质量影响的效果分析。方法以2012年10月-2012年12月、2013年1月-2013年3月及2013年4月-2013年6月三个阶段各随机抽取的1000份电子运行病历为研究对象,计算三个阶段病历的时限性缺陷、书写性缺陷及甲级率,结果使用SPSS11.0软件统计,率的比较采用χ2检验。结果 2013年1月-2013年3月与2012年10月-2012年12月比较,电子运行病历的时限性缺陷与书写性缺陷均下降(P<0.01),病案甲级率升高11.1%,乙级率下降15%(P<0.01),无丙级病历;2013年4月对电子病历缺陷实行奖惩后,电子运行病历时限性缺陷与书写性缺陷均下降(P<0.05),病案甲级率升高7.6%,乙级率下降2.6%(P<0.05)。结论环节质控是提高电子病历质量的重要方法,而奖惩措施是很好的助力。

Objective To explore the effect of step-by-step management and measure of rewards and punishments to electric medical records＇ quality. Methods Extracting randomly 1000 electronic running medical records from October 2012 to December 2012,from January 2013 to March 2013 and from April 2013 to June 2013 and calculate time-defects and writing defects of electric running medical records and the rate of class A in different three stages; Using SPSS11.0 and x2 test. Results Electric medical records in 2013 comparing with 2012, the time-defects and writing defects both decrease （P〈0.01）, the rates of class A increase 11.1%, Class B decrease 15%（ P〈0.01 ）; After rewards and punishments from 2013 April, time-defects and writing defects both decrease（P〈0.05）, the rates of class A increase 7.6%, Class B decrease 2.6% （P〈0.05）. Conclusion Step-by-step management is an important way to improving the quality of electric medical records, rewards and punishments are good helping factors.