现代信息技术在病案管理中的应用效果分析

Application Effect Analysis of Modern Information Technology in Medical Record Management

目的:分析现代信息技术在病案管理中的应用效果。方法:随机选取遵义市汇川区中医医院2020年6月—2021年5月管理的500份病案作为管理前组,随机选取2021年6月—2022年5月管理的500份病案作为管理后组。管理前组实施常规模式管理,管理后组实施现代化信息技术管理。比较两组管理效果。结果:管理后组文书整理、病案整理耗时、病案信息记录完整性、病案存放效率评分高于管理前组,差异有统计学意义(P<0.001)。管理后组病案缺页缺项率、首页不合格率、医疗纠纷率均低于管理前组,差异有统计学意义(P<0.001)。管理后组病案调阅时间、复印时间短于管理前组,差异有统计学意义(P<0.001)。结论:现代信息技术在病案管理中的应用效果显著,可提高病案管理工作质量、病案管理专项质量,缩短病案调阅、复印时间。

Objective:To analyze the application effect of modern information technology in medical record management.Methods:A total of 500 medical records managed by Huichuan District Hospital of Traditional Chinese Medicine in Zunyi City from June 2020 to May 2021 were randomly selected as the pre-management group,and 500 medical records managed from June 2021 to May 2022 were randomly selected as the post-management group.The pre-management group implemented conventional management mode,and the post-management group implemented modern information technology management.The management effect was compared between the two groups.Results:The scores of document organization,medical record organization time,completeness of medical record information recording,and efficiency of medical record storage in the post-management group were higher than those in the pre-management group,and the difference was statistically significant(P<0.001).The rate of missing pages and items in medical records,the rate of unqualified homepage,and the incidence of medical disputes in the postmanagement group were lower than those in the pre-management group,and the difference was statistically significant(P<0.001).The time of medical record retrieval and copying in the post-management group was shorter than that in the pre-management group,and the difference was statistically significant(P<0.001).Conclusion:The application of modern information technology has significant effects in medical record management,and can improve the medical record management quality and medical record management special item quality,and shorten the time of medical record retrieval and copying.