电子病历系统质控功能完善对提高医院病案质量的作用分析

Analysis of the effect of improving the quality control function of electronic medical record system on improving the quality of hospital medical records

目的分析电子病历系统质控功能完善对提高医院病案质量的作用。方法回顾性分析某院电子病历质控功能完善前后的相关资料.2018年9月-2020年9月实施电子病历质控功能完善,将此期间5877例出院患者的病案纳入研究,作为研究组。将质控功能完善前(2016年8月-2018年8月)5898例出院患者病案作为对照组.观察两组病案质量(病案管理过程、病案书写评价、病案缺陷、病案返修)、终末病案返修率、病案书写及时率及终末病案甲级率.结果研究组病案管理过程、病案书写评价、病案缺陷、病案返修及病案质量总评分均高于对照组(P<0.05);研究组终末病案返修率(0.36%)低于对照组(1.14%),病案书写及时率(99.59%)高于对照组(98.03%)(P<0.05);两组终末病案甲级等级分布比较,差异有统计学意义(P<0.05),研究组终末病案甲级率(73.12%)高于对照组(64.29%)(P<0.05)。结论电子病历系统质控功能完善能显著提升医院病案质量,确保病案书写及时率,有效降低终末病案返修率.

Objective Ohjective to analyxe the role of improving the quality control function of electronic medlical reeord system in improving the quality of hospital medical records.Methods Retrmspective analysis of our hoespital electronic merdical record quality control function belfore and after the improvement of the relevant data.From September 2018 to September 2020.the quality control function of EMR was improved.and the medical records of 5877 discharged patients during this period were includled in the studly as the research group.5898 rdischarged patients belfore the improvement of quality control function(August 2016-August 2018)were selected as the controlpgroup.The melical recorl quality(medlical record management process.medical record writing evaluation.melical record defert.meticalrecord repair).final medlical record repair rate.timely medical record writing rate and final medlical record grade a rate were observed.Results The total scores of medlical record management process,medical record writing evaluation,melical record defects,medlicalrecord repair and medlical record quality in the studly group were higher than those in the control group(P<0.05).The repair rate of finalmedical records in the study group(0.36%)was lower than that in the control group(1.14%),and the timely writing rate of medlical records(99.59%)was higher than that in the control group(98.03%)(P<0.05).The difference in the grade A distribution of terminal medicalrecords hbetween the two groups was statistically significant(P<0.05).The grade A rate of terminal medlical recorls in the stuly group(73.12%)was higher than that of the control group(64.29%)(P<0.05).Conclusion The perfect quality control function of EMR systemcan significantly improve the quality of hospital medical records.,ensure the timeliness of medlical recordls writing.and effectively rertuce therepair rale of final medlical records.