电子病历实时监控系统在病案管理中的作用

The Function of Electronic Medical Record Real-time Monitoring System in Medical Record Management

目的探讨某二甲医院应用电子病历实时监控系统对病案管理的促进作用,了解其病案内涵质量、病案差错率、归档率情况,为病案管理持续质量改进提供有效措施。方法随机选取2018年1—12月的300例出院病案为对照组,2019年1—12月的300例出院病案为研究组,对照组开展常规病案管理,研究组在对照组基础上,应用电子病历实时监控系统。结果研究组病案内涵质量均明显高于对照组(P<0.05);研究组病案差错率(3.00%)明显低于对照组12.00%(P<0.05);研究组出院病案3天内归档率(96.00%)显著高于对照组(81.67%)(P<0.05)。结论电子病历实时监控系统对病案管理的促进作用较为显著,可做到实时监控、实时检查、实时反馈、医生及时整改,使病历质量管理由原先手工书写的事后控制转变为对各项质量监控指标实行实时动态事中过程的质量控制,保障医疗质量与安全,提高工作效率与数据质量,为医院有效实施DRGs作铺垫。

Objective To explore the promotion of the application of electronic medical record real-time monitoring system to the medical record management in a first-class hospital,and to understand the connotation quality,error rate and filing rate of the medical record,so as to provide effective measures for the continuous quality improvement of the medical record management.Methods 300 discharged medical records from January to December 2018 were randomly selected as the control group,and 300 discharged medical records from January to December 2019 were selected as the study group.The control group carried out routine medical record management,and the study group applied electronic medical record real-time monitoring system on the basis of the control group.Results The quality of medical records in the study group was significantly higher than that in the control group(P<0.05);the error rate of medical records in the study group was 3.00%,which was significantly lower than that in the control group(12.00%)(P<0.05);the filing rate of medical records in the study group within three days after discharge was 96.00%,which was significantly higher than that in the control group(81.67%)(P<0.05).Conclusion Electronic medical record real-time monitoring system has a significant role in promoting medical record management.It can achieve real-time monitoring,real-time inspection,real-time feedback,and realtime rectification by doctors,so that the quality management of medical records can be changed from the original manual written post event control to the real-time dynamic process quality control of various quality monitoring indicators,ensuring medical quality and safety,and improving work efficiency and data Quality is the foundation for the effective implementation of DRGs in hospitals.