病案管理信息化应用效果分析

Analysis of Application Effect of Medical Records Management Informatization

目的系统分析医院病案管理借助信息化手段,在工作效率和工作质量方面取得的效果,供同行参考借鉴。方法采用计量资料的加和方法,分析某三级中医医-院2011年-2017年共66 206份出院病案及在院运行病历在病案首页信息采集与编辑、病案索引与查询、病案示踪、病案调取、环节病历质控五个环节的时间数据和质量数据。结果 7年里,在借助信息化手段以后,累计节省工时13 557.1小时,病案首页信息填写质量、借出病案按时入库率及环节病历书写质量显著提高,医师调取数字化病案份数逐年上升。结论病案管理信息化应用,显著提高工作效率和工作质量,值得广泛推广并进一步深化应用。

Objective This paper systematically analyzes the effect of hospital medical record management in terms of working efficiency and working quality by means of information technology, which can be used for reference by peers. Methods By using the summation method of metrological data, a total of 66 206 medical records from 2011 to 2017 in a tertiary TCM hospital were analyzed. The medical records were collected and edited on the first page of the medical records, the index and query of medical records, the tracer of medical records and the transfer of medical records, time data and quality data of five links of medical record quality control were analyzed. Results In the past seven years, with the help of information technology, the total saving time was 13557.1 hours. The quality of medical record home page information was filled in, the quality of the medical records was checked and the quality of medical records was significantly improved, and the number of doctors who took digital medical records was increasing year by year. Conclusion The application of medical records management informatization significantly improves the work efficiency and quality of work, and it is worth popularizing and further deepening the application.