网络实时监控对归档电子护理病历质量的影响  

Effect of real-time network monitoring on the quality of electronic nursing records

作　　者：李惠卿[1] 赵思煜[1] 洪春燕[1] 

机构地区：[1]汕头市中心医院中山大学附属汕头医院,515031

出　　处：《国际医药卫生导报》2013年第3期307-309,共3页International Medicine and Health Guidance News

基　　金：汕头市重点科技计划项目（汕府科[2011]46号42-39）

摘　　要：目的探讨电子护理病历网络实时监控对归档病历质量的影响。方法采用回顾性调查方式，随机抽查2011年4—7月归档的2750份电子护理病历（A组）进行终末质控，2012年4—7月网络实时监控后归档的2750份电子护理病历（B组）进行终末质控。调查分析护理病历退档修改情况。结果网络实时监控后归档电子护理病历与网络实时监控前归档电子护理病历比较，退档率下降，两组差异有统计学意义（P〈0．01）。结论在传统三级质控、定期抽查评比的管理模式基础上，增加网络实时监控，能有效提高护理病历质量。Objective To explore the influence of real-time network monitoring on the quality of elec- tronic nursing records. Methods A retrospective survey was conducted. 2750 electronic nursing records in group A which were filed during April to July 2011 were randomly selected for terminal quality control. After application of real-time network monitoring, 2750 electronic nursing records in group B which were filed during April to July 2012 were used for terminal quality control. The revise of all the nursing records was investigate and analyze. Results After application of real-time network monitoring, the rate of filing withdrawl was de- clined, as compared with that in the period without monitoring, with a statistical difference between the two groups. Conclusions On the base of the management pattern of traditional three-level control and inspection, the use of real-time network monitoring can effectively improve the quality of nursing records.

关 键 词：电子护理病历 实时监控 病历质量 

分 类 号：R47[医药卫生—护理学]