电子病案质量缺陷分析及对策研究  

Analysis and Strategy Research on the Quality Defects of Electronic Medical Records

作　　者：伍姗姗[1] 杨旭丽[1] 刘钰[1] 

机构地区：[1]南昌大学第一附属医院质控科,南昌市330006

出　　处：《中国病案》2010年第3期51-52,共2页Chinese Medical Record

摘　　要：目的分析电子病案现存的质量缺陷,为质量监控提供有针对性的策略;方法随机抽查1521份出院电子病案;结果1521份病案甲级率达90%以上,病程记录的缺陷最多,占21.09%,前15位缺陷占总缺陷的50%以上;结论加大病案质量的监管和处罚力度,抓住病案质量监控的重点和难点。Objective To provide a targeted strategy for the quality control of electronic medical records （EMR） by analyzing the existing quality defects of EMR.Methods Quality of 1521 discharged EMR by randomly sampling was checked.Results Among 1521 EMR,the rate of Class A is more than 90%,in which most defects existed in the course records,accounting for 21.09%,and defects in the top 15 accounted for more than half of the total defects.Conclusion In order to further standardize writing and improve the quality of medical records,we should strengthen the quality supervision and penalties and seize the focus and difficulties in the quality control of medical records.

关 键 词：电子病案 质量缺陷 分析 

分 类 号：R197.3[医药卫生—卫生事业管理]