电子病案首页填写存在的问题及对策研究

Problems Existing in the Filling of the Front Pages of Electronic Medical Records and Research on Relevant Countermeasures

目的通过对某医院电子病案首页基本信息、医疗信息填写情况进行漏报率和错误率的统计,依据结果进行原因分析,同时有针对性地提出改进对策。方法依据原卫生部的文件以及对电子病案首页相关文献的分析,根据某院各科病床的比例抽取2016年1月-2016年12月各科病案共3500份,对电子病案首页中易出现的问题进行卡方检验,各科病案的缺陷分布情况以Excel形式描述。结果某院电子病案首页在填写中存在缺项和填写不准确的现象,通过χ2检验,得出χ2=3715.15,P〈0.05,有统计学意义,各科病案首页的缺陷科室特点不同呈现差异。结论主观上让医务人员和患者重视,减少病案首页基本信息的漏填,客观上加强相关知识的培训,完善计算机筛查、提示系统,减少医疗及其他信息的错误率,同时进行不定期的质控,这样才能保证首页信息的准确性、完整性,更好的为医院管理服务。

Objectives Through the statistical analysis on the non-response rate and error rate of the front pages of the electronic medical records and the filling situation of medical information in a hospital, to conduct a reason analysis according to the results, and put forward some improving countermeasures pertinently. Methods Based on the documents of the ministry of health and the analysis of the related literatures on the front pages of electronic medical records, we selected a total of 3500 cases of medical records from all departments of 2016 in a hospital according to its sickbed ratio, then use chi-square test statistically analyzes problems easy to appear in the front pages of the electronic medical records, EXCEL table was adopted to calculate the proportion of issues item and compared the related departments. Results In this hospital, there were missing items and inaccurate writing phenomena in the front pages of the electronic medical records,through chi-square test,we could find x2= 3715.15, P〈0.05, it had statistical significance, while due to different characteristics of the department, the defects of the front pages of the electronic medical record were different. Conclusions Only subjectively let both the medical staff and the patients pay attention to it, could decrease the basic information of the front pages of medical record. Meanwhile, objectively strengthening the training of relative knowledge, improving the screening and prompting of computer system,could decrease the error rate of medical and other information carrying out regular quality control, could we ensure the accuracy and integrity of the homepage, making it better for the hospital management services.