探讨电子病案的应用对病案质量的影响

Discussion on the Influence of the Application of Electronic Medical Records on the Quality of Medical Records

目的探讨电子病案的应用对于提高病案质量的作用。方法针对厦门大学附属第一医院耳鼻喉科、眼科、康复科、妇科、产科2020年1月—2022年6月的病案进行随机抽检,选取1333份单否病历进行分析,对于单否问题进行总结、归纳,探究其原因。同时回顾性分析3500份电子病案进行调查研究,其中,加强质量管理前的病案1731份,加强质量管理后的病案1769份,进行病案质量的评价。结果在1333份单否病历中,存在1789个单否问题,主要包括病程记录不完整、病历中记录内容互相矛盾、会诊单无会诊意见、普通会诊未在会诊打出申请24 h或点名会诊未在48 h内完成、缺《术后首次病程记录》、缺《术前讨论记录》以及缺手术、操作同意书等。加强质量管理后,检查单缺陷率(0.11%)、医嘱单缺陷率(0.06%)、治疗记录单缺陷率(0.06%)、出院记录单缺陷率(0.11%)低于加强质量管理前(P<0.05);运行病案评价总分为(81.61±4.20)分,终末病案评价总分为(96.18±2.12)分,高于加强质量管理前(P<0.05)。结论电子病案的应用实现了数字化医疗服务,便于更加高效地开展各项诊疗、护理工作,可以减少病案中的项目遗漏、记录不全、填写错误等缺陷问题。在应用电子病案的过程中,同样需要严格进行监管,持续进行质量改进,降低病案缺陷率,充分保障病案质量。

Objective To explore the effect of electronic medical records on improving the quality of medical records.Methods The medical records in the department of otolaryngology,ophthalmology,rehabilitation,gynecology and obstetrics of the First Affiliated Hospital of Xiamen University from January 2020 to June 2022 were randomly sampled,and 1333 single or non-single medical records were selected for analysis.The problems of single or non-single medical records were summarized and concluded to explore the causes.A total of 3500 electronic medical records were retrospectively analyzed for investigation and research,including 1731 medical records before strengthening quality management and 1769 medical records after strengthening quality management to evaluate the quality of medical records.Results Of the 1333 single-no records,there were 1789 single-no problems.It mainly includes incomplete course records,contradictory contents recorded in medical records,no consultation advice on the consultation sheet,no general consultation issued within 24 h of the consultation application or no roll call consultation completed within 48 h,no"first postoperative course record",no"preoperative discussion record",and no consent for operation and operation.After strengthening quality management,the defect rate of inspection sheet(0.11%),doctor’s order sheet(0.06%),treatment record sheet(0.06%)and discharge record sheet(0.11%)was lower than that before strengthening quality management(P<0.05),and the total score of operating medical record evaluation was(81.61±4.20)points.The total score of terminal medical record evaluation was(96.18±2.12)points,which was higher than that before strengthening quality management(P<0.05).Conclusion The application of electronic medical records has realized the digital medical service,which is convenient to carry out the diagnosis and nursing work more efficiently,and can reduce the defects such as item omissions,incomplete records and filling errors in medical records.In the process of applying electronic medical records,strict supervision is also needed,continuous quality improvement is carried out,the defect rate of medical records is reduced,and the quality of medical records is fully guaranteed.