多院区电子病历质控系统的应用

Application of Electronic Medical Record Quality Control System in Multi-district Hospital

目的应用电子病历质控系统对某院住院病案进行质控,从而提高医院整体的病案质量。方法选取三院区2021年7月1日-2021年12月31日数据为对照组,人工质控病案1740份,电子系统自动质控33707份;2022年1月1日-2022年6月30日数据为观察组,人工质控病案1740份,电子系统自动质控34004份。人工质控病案合计3480份,电子系统自动质控病案合计67711份。使用电子系统质控与人工质控相结合的方法进行质控,分别比较对照组和观察组的住院甲级病案率、时效性条目完成率等指标。采用SPSS26.0统计软件对数据进行统计分析。结果对照组住院病案甲级率93.28%,观察组住院病案甲级率96.78%,比较χ^(2)=22.634,P<0.001,差异具有统计学意义。观察组入院记录在入院24小时内完成率较对照组明显提高,χ^(2)=301.792;观察组首次病程记录在入院8小时内完成率较高于对照组,χ^(2)=188.213;观察组入院48小时内上级医师首次查房记录完成率高于对照组,χ^(2)=230.332;观察组入院72小时内主任医师首次查房记录完成率较高于对照组,χ^(2)=320.246;观察组患者出院后24小时内出院记录完成率高于对照组,χ^(2)=74.172,P<0.001,差异均具有统计学意义。结论在大型多院区综合医院中运用电子病历质控系统进行病案质量管理,可以有效地提高病案完成的时效性,改善医院的病案质量,是新形势下病案质量管控的重要举措。

Objectives The electronic medical record quality control system was used to control the quality of the inpatient medical record of a hospital,so as to improve the overall quality of the hospital medical record.Methods Selecting data from July 1st,2021 to December 31st,2021 from the hospital as the control group,1740 medical records were manually controlled and 33707 were automatically controlled by electronic systems.From January 1st,2022 to June 30th,2022,the data for the observation group consisted of 1740 manually controlled medical records and 34004 automatically controlled electronic systems.There are a total of 3480 manual quality control medical records and 67711 electronic system automatic quality control medical records.The method of combining electronic system quality control with manual quality control is used for quality control,and the inpatient grade A medical record rate and timeliness item completion rate of the control group and the observation group are compared.Use SPSS 26.0 statistical software to conduct statistical analysis on the data.Results The Grade A rate of inpatient medical records in the control group was 93.28%,and the observation group's inpatient medical record grade A rate is 96.78%,the difference between the two was statistically significant(χ2=22.634,P<0.001).The completion rate of admission records within 24 hours of admission in the observation group was significantly higher than that in the control group(χ2=301.792),the completion rate of the first course record within 8 hours of admission in the observation group was significantly higher than that in the control group(χ2=188.213),and the completion rate of the first ward round record of the superior physician within 48 hours of admission in the observation group was significantly higher than that in the control group(χ2=230.332),the completion rate of the first ward round record of the chief physician within 72 hours of admission in the observation group was significantly higher than that in the control group(χ2=320.246),and the completion rate of the discharge record within 24 hours in the observation group was significantly higher than that in the control group(χ2=74.172).The above results were all P<0.001,the difference was statistically significant.Conclusions The use of electronic medical record quality control system for medical record quality management in large multi-district comprehensive hospitals could effectively improve the timeliness of medical record completion and improve the quality of medical records in the hospital.It was an important measure for medical record quality control in the new situation.