电子病历在线质控住院病案首页的缺陷分析

Analysis of Defect in Front Pages of Inpatient Medical Records under Online Quality Control Mode of Electronic Medical Records

目的进一步提高医师填写住院病案首页的数据质量。方法导出2018年1月1日-2018年12月31日期间的电子病历在线质控系统中医师填写病案首页错误的全部质控驳回记录,运用Microsoft Office Excel 2010进行归纳、整理及运算,回顾性分析该质控模式下医师填写病案首页的错误情况。结果医师填写并提交的待审核电子病历首页中,诊疗信息错误11404条,占71.39%;A类信息错误8666条,占59.45%;关键信息错误10278条,占18.46%。结论虽然电子病历在线质控模式下的病案首页数据质量可以通过信息化的环节质控而得到极大的保证,但是医师填写病案首页存在较高的错误率也是不容忽视的,需要进一步针对主要问题加以改进。

Objectives To further improve the data quality of doctors filling in the front pages of inpatient medical records.Methods Retrieving and deriving from the system all the quality control rejection records of the front pages errors filled by the doctors in the online quality control system of electronic medical records from January 1 st,2018 to December 31 st,2018,using Microsoft Office Excel 2010 to summarize,collate and calculate,and retrospectively analyzing the errors of the doctors in filling in the front pages under the quality control mode.Results In the front pages of electronic medical records to be examined and submitted by physicians in 2018,there were 11404 errors in diagnosis and treatment information,with a constitutive ratio of 71.39%;8666 errors in category A,with a constitutive ratio of 59.45%;and 10278 errors in key information,with a proportion of 18.46%.Conclusions Although the quality of front pages data in the online quality control mode of electronic medical records could be greatly guaranteed through the quality control of informationization links,the high error rate of doctors filling in key information on front pages could not be ignored,and further improvement was needed for the main problems.