屏幕截图在电子病历环节质控中的应用

Application of Screenshot in the Links Quality Control of Electronic Medical Records

目的探讨通过屏幕截图进行电子病历环节质控的方法在提高病案书写质量中的效果。方法随机抽取2011年7月至2013年6月两年内共3960份运行病历进行质量监控(程序监控辅以人工检查),前12月的检查结果以文本形式反馈给医师,后12个月质控检查时增加对病历缺陷进行屏幕截图,检查结果以图片加文本形式反馈给医师,最后对屏幕截图实施前后每月存在的各种类型缺陷数量进行统计分析。结果通过屏幕截图法进行病历质量监控后病案缺陷的数量比屏幕截图前明显减少(P<0.01)。结论通过屏幕截图进行电子病历环节质控能有效减少病案缺陷,明显提高病历质量。

Objectives To discuss the effect of screenshot in the quality improvement of medical record writing in the links quality control of electronic medical records. Methods 3960 copies of running medical records were selected randomly from July 2011 to June 2013, and they were received quality monitoring （Program monitoring combined with manual inspection）. The results of the previous twelve months be back to doctors in text form, while the posterior twelve months in text plus screenshot form, and finally the statistical analysis on the number of various types of defects existed before and after the implementation of screenshots was taken monthly. Results The application of screenshots significantly reduced the number of defects in medical records compared with before （P〈 0. 01）. Conclusions To conduct links quality control of electronic medical records with the application of screenshot could reduce defects effectively and improve the quality of medical records obviously.