1300份电子病案环节质量与终末质量缺陷比较分析  

A Defects Comparative Analysis on Segment Quality and Final Quality of 1300 Electronic Medical Records

作　　者：杨琴[1] 李天资[1] 

机构地区：[1]广西百色市右江民族医学院病案室

出　　处：《中国病案》2011年第7期23-24,共2页Chinese Medical Record

摘　　要：目的分析电子病案缺陷特征,探讨提高病案内涵质量措施。方法对医院2010年下半年1300份电子病案的环节质量与终末质量缺陷进行比较分析。结果病案环节质量的缺陷数是1500处,终末病案缺陷数580处。环节质量缺陷率比终末质量缺陷高,两组比较有差异有统计学意义(χ2=32.4,P<0.05)。结论病案环节质量监控比较薄弱,病案环节质量缺陷问题突出,加强病案室质控组力量,强化科室三级实时监控网,实现环节质量控制与终末质量控制并重,是提高病案内涵质量的关键。Objectives Having an analysis on defects characteristic of electronic medical records for investigating connotation quality countermeasures improvement of medical records.Methods Defects of segment quality and final quality of 1300 medical records the second half year of 2010 are comparatively analyzed.Results The defects numbers of segment quality are 1500;the defects numbers of final medical records are 580.The defect rate of segment quality is higher than final quality.There are difference and statistic meaning of comparison between these two groups（χ 2 =32.4,P0.05）.Conclusions The segment quality monitor of medical records is relative weak whose defect problems are serious.We should strengthen quality control force in medical records office and three level real-time monitor net in clinical department,achieving equal attention of segment quality control and final quality control,which are the keys to improve connotation quality of medical records.

关 键 词：病案环节质量 监控 缺陷 实时监控 

分 类 号：R197.3[医药卫生—卫生事业管理]