电子病历质量控制及保障措施研究

Research on Quality Control and Protection Measures of Electronic Medical Records

目的：对病历质量缺陷及其成因进行分析，提出实用性病历质量保障措施。方法选择我院2014年1～6月的电子病历6500份，此次抽检率可达21.3%。结果病历形成时，部分内容记录并不完整，使得病历实用性不高。结论构建适宜的质量管理体系，且不断强化电子病历环节质控，提升医务人员综合素质，对病历质量保障及医疗质量控制有重要意义。

Objective Defects and Causes of the quality of medical records were analyzed,and put forward the medical quality assurance measures. Methods6 500 electronic medical records in our hospital from January to June 2014 in our hospital were selected,the sampling rate was up to 21.3%. ResultsWhen the formation of medical records,part of the contents of the record was not completed,making the medical record was not high. ConclusionConstruction of appropriate quality management system,and constantly strengthen the electronic medical records link quality control, improve the comprehensive quality of medical personnel,for medical records quality assurance and medical quality control has important significance.