电子病历在被借阅与复印病案管理中的运用及归档质控影响分析

Analysis of the Use of Electronic Medical Records in the Management of Borrowed and Copied Cases and the Impact of Archiving Quality Control

目的探讨电子病历在妇幼保健院被借阅与复印病案管理中的运用及归档质控影响分析。方法选取2020年7月—2022年8月福州市妇幼保健院病案室病历680份作为研究对象,将2020年7月—2021年7月实施传统手写病历340份纳入对照组,将2021年8月—2022年8月(2021年10月执行新系统)实施电子病历340份纳入观察组。对比不同组别的病历质量评分、病历书写缺陷率、护理人员对病历使用的便捷率。结果观察组的病案首页、入院记录、病程记录、出院记录、治疗、辅助检查、基本要求及医嘱单及总分分别为(2.70±0.46)分、(23.24±1.35)分、(32.45±2.88)分、(4.50±0.60)分、(5.20±0.50)分、(5.50±0.50)分、(8.85±1.21)分、(82.44±5.46)分;对照组分别为(2.00±0.01)分、(20.81±1.13)分、(29.54±1.84)分、(3.64±0.66)分、(3.90±0.30)分、(4.00±0.45)分、(7.76±1.25)分、(71.66±4.56)分,2组比较,观察组更高(P<0.05)。观察组的基础护理漏写、不能体现专科情况、护理记录不及时、病情评估与描述不准确、生命体征与体温单不符、与医师记录不一致等缺陷率分别为3.24%、4.12%、2.94%、2.35%、2.65%、2.06%,对照组分别为6.76%、9.41%、6.47%、5.59%、6.18%、5.00%;2组比较,观察组更低(P<0.05)。观察组的病历借阅时间(2.51±0.85)min、病案复印时间(5.24±1.89)min、首页录入时间(3.33±0.89)min,均短于对照组(6.41±1.54)min、(9.42±2.47)min、(6.66±1.63)min(P<0.05)。结论电子病历在妇幼保健院被借阅与复印病案管理中有利于提高病历质量和降低病历书写缺陷率,以及提高护理人员对病历使用的便捷。

Objective To explore the application of electronic medical records in the management of borrowed and copied medical records in maternal and child health centers,and to analyze the impact of archiving quality control.Methods A total of 680 medical records from the medical record room of Fuzhou Maternity and Child Health Care Hospital from July 2020 to August 2022 were selected as the research subjects.340 traditional handwritten medical records implemented from July 2020 to July 2021 were included in the control group,and 340 electronic medical records implemented from August 2021 to August 2022(new system launched in October 2021)were included in the observation group.The quality scores of medical records in different groups,the defect rate of medical record writing,and the convenience rate of nursing staff in using medical records were compared.Results The observation group's medical record homepage,admission records,course records,discharge records,treatment,auxiliary examinations,basic requirements and medical orders,as well as total scores,were(2.70±0.46)points,(23.24±1.35)points,(32.45±2.88)points,(4.50±0.60)points,(5.20±0.50)points,(5.50±0.50)points,(8.85±1.21)points,and(82.44±5.46)points,respectively;The control group was divided into(2.00±0.01)points,(20.81±1.13)points,(29.54±1.84)points,(3.64±0.66)points,(3.90±0.30)points,(4.00±0.45)points,(7.76±1.25)points,and(71.66±4.56)points,respectively,it was higher in observation group(P<0.05).The defect rates of basic nursing in the observation group were 3.24%,4.12%,2.94%,2.35%,2.65%and 2.06%,respectively,such as omission of basic nursing,failure to reflect specialty conditions,untimely nursing records,inaccurate condition assessment and description,inconsistency between vital signs and body temperature sheets,and inconsistency with physician records.The control group was 6.76%,9.41%,6.47%,5.59%,6.18%,5.00%,and the observation group was lower than the two groups(P<0.05).The medical record borrowing time(2.51±0.85)min,medical record copying time(5.24±1.89)min,and home page entry time(3.33±0.89)min in the observation group were shorter than those in the control group(6.41±1.54)min,(9.42±2.47)min,(6.66±1.63)min(P<0.05).Conclusion The use of electronic medical records in the management of borrowing and copying medical records in maternal and child health centers is beneficial for improving the quality of medical records,reducing the rate of medical record writing defects,and improving the convenience of nursing staff in using medical records.