智能化电子病历质控体系构建与应用

Construction and Application of Intelligent Electronic Medical Record Quality Control System

目的对宁夏某三甲医院应用智能化电子病历质控体系的效果进行评估,为病案质控持续改进提供依据。方法按5%的比例随机抽取某院每个月的终末病案质控数据,以2020年1月1日-2020年12月31日的3795例实行人工质控的数据作为对照组,以2021年1月1日-2021年12月31日的4809例实施智能化三级质控管理的数据作为观察组,对比2组实施智能化电子病历质控体系应用前后病案质量评分和病案缺陷的变化情况。结果对照组的病案质量评分为(87.83±10.35)分,观察组为(94.40±8.19)分,观察组电子病历完整性和逻辑性缺陷数量排名前10的项目中无上级医师日常查房或同意出院记录占比由18.1%降至2.22%,入院病情填写错误由12.33%降至5.45%。经比较除诊断书写不规范和知情同意书勾选不完全2组比较,P>0.05差异无统计学意义外,其余项2组比较,P<0.5,差异具有统计学意义。观察组未在患者住院24小时内完成入院记录占比由25.03%降至2.33%,无患者入院前3天连续病程记录由22.71%下降至2.18%,其余病案时限性缺陷项目占比也明显下降,2组比较,P<0.5,差异具有统计学意义。结论实施智能化电子病历质控管理能够规范电子病历书写内容,有效提升电子病历质量,减少病案缺陷和不良事件的发生。

Objectives In order to provide a basis for continuous improvement of medical record quality control,an intelligent electronic medical record quality control system was established in a Three A and Tertiary Hospital in Ningxia and its application effect was analyzed.Methods The monthly quality control data of terminal medical records in hospitals were randomly selected according to the proportion of 5%.The data of 3795 cases with manual quality control from January 1st to December 30th,2020 were used as the control group,and the data of 4809 cases with intelligent three-level quality control from January 1st to December 31st,2021 were used as the observation group.The changes of medical record quality score and medical record defects before and after the implementation of intelligent electronic medical record quality control system were compared and analyzed.Results Before the system was implemented,the score of medical record quality was(87.83±10.35),and after the system was implemented,it was increased to(94.40±8.19).The number and rate of various defects in medical records also decreased significantly,with statistical significance(P<0.05).Conclusions The implementation of intelligent electronic medical record quality control management could standardize the content of electronic medical record,effectively improve the quality of electronic medical record,and reduce defects in medical records and adverse events.