电子病历质检体系的持续改进

Discussion of Continuous Improvement Practice of Electronic Medical Record Quality Control System

目的剖析目前运行病历质检的缺陷,探讨提高运行病历的完成质量的持续改进的措施,以促进医疗质量的全面提升。方法分别于2012年及2013年抽取外科电子病历及内科电子病历,统计缺陷病历的情况应用SPSS15.0统计软件进行分析,采用t检验处理和统计。结果外科组、内科组改进后缺陷份数百分比明显下降,有显著差异且有统计学意义(P<0.01);改进后百分比平均值均明显低于改进前,有显著差异且有统计学意义(P<0.01)。改进后的2013年病历质检的平均分明显高于同期2012年病历质检的平均分。从而促进甲级病案率的提升及医疗纠纷数明显下降。结论完善电子病历环节质控系统及信息化管理,加强持续改进,使运行病历质量不断提升,不仅有效降低医疗风险,也是全面提升医疗内涵质量的一个重要的环节。

Objective To analyze the defects of the running medical records, and to find continuous improvement measures for improving the quality of running medical records, so as to promote the medical quality comprehensive improvement. Methods Selecting surgical and internal medical electronic medical records respectively in 2012 and 2013. Calculating and comparing defect rate of copies and defect rate of times. Analyzing data by SPSS15.0 and processing and calculating data by t-test. Results The percentage of Defects copies was decline sharply after improvement. There are significant difference with statistical significance（P〈0.01）;The average percentage were significantly lower than before improvement, there are significant difference with statistical significance （P〈0.01）. The improved average score of 2013 was obviously higher than the same period in 2012. The Running medical records quality has increased, and the number of medical disputes has declined obviously.Conclusion We should improve the Link quality control of electronic medical record and information management, strengthen the continuous improvement, not only effectively reduce the medical risk, but also comprehensively enhance the connotation of medical quality.