护理电子病历质控体系优化及效果分析

Optimization and Effect Analysis of Quality Control System of Nursing Electronic Medical Records

目的按照国家卫健委6级电子病历应用水平要求,探讨质控体系在护理电子病历质控中的应用与效果。方法基于国家卫健委6级电子病历应用水平中提出的“全流程医疗数据闭环管理、高级医疗决策支持”核心要求,构建医院护理电子病历智能质控体系,运用医院数据集成平台,按照护理质控规则自动定时抓取数据,进行分析,实现对电子病历的智能质控应用。结果护理电子病历智能质控系统上线第3个月,护理记录评估总漏评率下降到4.14%,显著低于第1、2个月(9.56%、7.23%),在跌倒、压力性损伤、VTE、疼痛、入院评估5个质控项目的漏评率均显著低于前两个月;平均每份电子病历智能质控耗时(1.61±0.07)分钟,显著少于传统质控耗时(12.25±0.38)分钟;护士对护理电子病历智能质控的满意度92.63±2.18分,显著高于传统质控满意度的76.65±1.44分。结论按照国家卫健委6级电子病历应用水平要求建立的护理电子病历智能质控体系能降低护士对护理电子病历质控耗时,提升护士对护理电子病历质控的满意度,护理电子病历智能质控体系使用3个月来,护士在护理文书各节点的漏评率逐步降低。

Objective To explore the application and effect of quality control system on nursing electronic medical records according to the requirements of Level-6 Electronic Medical Record Application of National Health Commission.Methods Based on the core requirements of"whole process medical data closed-loop management,advanced medical decision support"proposed by the National Health Commission in Level-6 Electronic Medical Record Application,the intelligent quality control system of hospital nursing electronic medical records was constructed.The data was automatically captured and analyzed according to the nursing quality control rules by using the hospital data integration platform,so as to realize the intelligent quality control application of electronic medical records.Results In the third month after the implementation of intelligent quality control system for nursing electronic medical records,the total missing evaluation rate of nursing records evaluation decreased to 4.14%,which was significantly lower than that in the first and second months(9.56%and 7.23%).The missing evaluation rates of five quality control items,including fall,pressure injury,VTE,pain and admission evaluation,were significantly lower than that in the first two months.The average time of intelligent quality control per electronic medical record was(1.61±0.07)minutes,significantly less than the traditional quality control time(12.25±0.38)minutes.The satisfaction scores of nurses to the intelligent quality control of nursing electronic medical records was 92.63±2.18 points,which was significantly higher than 76.65±1.44 points of traditional quality control satisfaction.Conclusion The establishment of intelligent quality control system for nursing electronic medical records according to the requirements of national Level-6 Electronic Medical Record Application can reduce the nurses'time-consuming on quality control of nursing electronic medical records,and improve the nurses'satisfaction with nursing electronic medical record quality control.Since the implementation of the intelligent quality control system in the past three months,the missing evaluation rate of nurses in each node of nursing documents has gradually decreased.