4856份急诊留观病历书写质量分析

Analysis on 4856 Cases of Medical Records in Emergency Department

目的分析某三甲医院急诊留观计算机打印病历的质量缺陷,探讨急诊留观病案的现状,为向电子病历过度做好准备。方法以卫生部病历书写基本规范为标准,对某三甲医院急诊留观2013年1月-2014年4月16个月的病案进行质量分析。结果 4856份急诊留观病案中,缺陷病案1235份,缺陷率25.43%。主要存在问题包括病程记录中使用复制粘贴现象严重,不同上级医师查房记录雷同,占23.08%。另外,医师审签工作滞后,占31.4%,病历归档时间滞后,占21.13%。结论现阶段急诊留观病案与真正意义上的电子病历还有一段距离,通过开发使用真正意义的急诊留观电子病历系统,从根本上解决存在的问题,切实提高病案质量。实现病案为临床、科研等方面服务的目的。

Objectives To analyze the quality defects existing in the computer printed medical records in emergency department of a grade A and tertiary hospital, investigate the current situation of medical records in emergency department and make preparation for the transition to electronic medical records. Methods To conduct a quality analysis on the medical records of patients over 16 months in emergency department of a grade A and tertiary hospital according to the standard of medical records writing rules announced by the ministry of health. Results There were 1235 cases existing defects in all the 4856 cases of medical records in emergency department, the defect rate was 25.43%. The mainly problems included serious phenomena of duplication and copying in the progress records, as well as similar round records of superior doctors, which accounting for 23.08%, In addition, the signature work of doctors was delayed, which accounting for 31.4%, and the archived time of medical records was lag behind, which accounting for 21.13%. Conclusions It was still many differences between the current medical records and the real electronic medical records in emergency department. Through the development of electronic medical records system in emergency department truly, we could solve the problems fundamentally and improve the quality of medical records, thus realize the goal of providing service for aspects such as clinical and research work.