摘要
目的分析微信APP对妊娠糖尿病病案管理质量的影响。方法将2015年1月1日-2016年12月31日未应用微信APP管理的妊娠糖尿病病案案200例纳入对照组;将2017年1月1日-2018年12月31日应用微信APP管理的妊娠糖尿病病案200例纳入研究组。比较2组病案合格情况、纠纷病案情况、病案书写质量及管理满意度。结果研究组病案合格率为91%,高于对照组(P<0.05)。研究组纠纷病案率低于对照组(P<0.05)。研究组妊娠糖尿病病案治疗目的完整占91%、适应症完整占88%、禁忌症完整占85%、入院病史完整占90%、当日治疗信息完整率占90.5%,高于对照组(P<0.05),不完整率低于对照组(P<0.05)。研究组管理总满意度为97%,高于对照组(P<0.05)。结论微信AAP参与妊娠糖尿病病案管理能明显减少纠纷病案,提高病案管理质量,应推荐使用。
Objective To analyze the influence of WeChat APP on the management quality of gestational diabetes records.Methods 200 cases of gestational diabetes cases not managed by WeChat APP from January 1 st,2015 to December 31 st,2016 were included in the control group.200 cases of gestational diabetes records managed by WeChat APP from January 1 st,2017 to December 31 st,2018 were included in the study group.The two groups were compared in terms of qualified medical records,medical records of disputes,writing quality and management satisfaction.Results The qualified rate of medical records in the study group was 91%,higher than that in the control group(P<0.05).The rate of medical records in the study group was lower than that in the control group(P<0.05).In the study group,91%of the patients with GDM had complete treatment purpose,88%of the patients with GDM had complete indications,85%of the patients with GDM had complete contraindication,90%of the patients with GDM had complete medical history,and 90.5%of the patients with GDM had complete treatment information,which was higher than that of the control group(P<0.05)and lower than that of the control group(P<0.05).The total management satisfaction of the study group was 97%,higher than that of the control group(P<0.05).Conclusions WeChat APP participating in the medical record management of gestational diabetes mellitus could significantly reduce medical record disputes and improve the quality of medical record management.
作者
王馨
高洁
宋志慧
Wang Xin;Gao Jie;Song Zhihui(Department of Medical Records,Tangshan Maternal and Child Health Hospital,Tangshan 063000,Hebei Province,China;不详)
出处
《中国病案》
2020年第5期38-41,共4页
Chinese Medical Record
关键词
微信APP
妊娠糖尿病
病案
管理
质量
WeChat APP
Gestational diabetes
Medical record
Management
Quality