基于根因分析法管理措施在电子病案首页管理中的应用效果

The Application Effect of Management Measures Based on Root Cause Analysis on the Homepage Management of Electronic Medical Records

目的评估电子病案实施根因分析法管理的效果及安全性。方法选取2020年5月—2021年5月日照市中心医院800份电子病案予以项目研究,以病案时间分为对照组(n=400,常规管理)、观察组(n=400,根因分析法管理),统计对比两组管理前后病案管理评分、病案首页质量评分、病案管理错误及病案归档情况。结果管理前两组医务人员病案管理评分、病案首页质量评分对比,差异无统计学意义(P>0.05)。管理后,观察组重要性认知、信息填写、考核制度、质量控制管理评分及首页基本信息、手术操作、编码信息质量评分较对照组高,差异有统计学意义(P<0.05);观察组的电子病案的病案诊断错误、疾病编码错误、手术编码错误、填写不规范、缺项漏项发生率低于对照组,差异有统计学意义(P<0.05);观察组电子病案的普通病案、死亡病案归档比例优于对照组,差异有统计学意义(P<0.05)。结论电子病案首页管理期间,实施根因分析法管理效果确切,可有效提升医务人员对病案首页质量的认知水平,其病案首页质量水平有所提升,临床病案首页错误率降低,病案归档比例相对较高。

Objective To evaluate the effect and safety of root cause analysis management of electronic medical records.Methods From May 2020 to May 2021,800 electronic medical records of Rizhao Central Hospital were selected for project study.They were divided into control group(n=400,routine management)and observation group(n=400,root cause analysis method)by medical record time.The medical record management scores,medical record homepage quality scores,medical record management errors,and medical record filing were statistically compared between the two groups before and after management.Results Before electronic medical record management,there was no significant difference in medical record management score and medical record homepage quality score between the two groups(P>0.05).After management,the observation group had higher scores on importance cognition,information filling,assessment system,quality control management scores,and basic information on the homepage,surgical operation,and coding information quality scores than those in the control group,the difference was statistically significant(P<0.05).In the electronic medical records of the observation group,the incidence rate of medical record diagnosis errors,disease coding errors,surgical coding errors,irregular filling,and missing items was lower than that of the control group,the difference was statistically significant(P<0.05).The electronic medical records of the observation group were better than those of the control group in the proportion of general medical records and death medical records,and the difference was statistically significant(P<0.05).Conclusion During the period of electronic medical record homepage management,the implementation of root cause analysis method has an accurate management effect,which can effectively improve the medical staff's cognition level of the medical record homepage quality,and the medical record homepage quality level has been improved.The error rate of the first page of clinical medical records is reduced,and the proportion of medical records filing is relatively high.