实施电子病案系统对病案质量的影响及原因分析  

Influence and Reason Analysis of the Electronic Medical Record System for Hospital Medical Record Quality

作　　者：李超[1] 盖媛媛[1] 窦婧婧[1] 徐锡武[1] 孙鹏程[1] 

机构地区：[1]北京医院医务处,北京市100730

出　　处：《中国病案》2013年第11期17-19,共3页Chinese Medical Record

摘　　要：目的研究电子病案系统的实施对医院病案质量的影响。方法根据质控医师对全院病案的定期检查,选取15个临床科室的病案缺陷率,采用SAS软件的重复测量分析方法对实施电子病案前后四年病案质量缺陷率进行分析。结果电子病案的实施初期导致医院总体病案缺陷率有所上升,影响因素主要有以下五点,(1)不断有新来院实习医师及进修医师书写病案;(2)医师未养成打印病案后及时签名的习惯,未签字缺陷占2012年全年病案缺陷比例的28.5%;(3)病案中必填项目未填写,该缺陷占2012年全年病案缺陷比例的22.1%,而上述两项缺陷在电子病案未实施前基本不存在;(4)电子病案暴露出的病案缺陷,易于质控,2012年病案内涵质量的缺陷比例占该年病案缺陷的13.4%,而相对比未实施电子病案的2010年和2009年,该类缺陷比例只占8.3%和6.5%。(5)质控医师水平的不断提高及质控范围的不断扩大,增强了麻醉记录,输血单,输血记录,消化内镜检查报告,支气管镜检查报告等部分的质控,该部分检查出的病案缺陷占2012年全年病案缺陷的2.5%;结论电子病案的实施有利于医院病案质量的监控及持续改进。Objective To study the impact of implementation of the electronic medical record system to the quality of hospital medical record. Methods Based on the date of our hospital＇ s daily check of medical record, we selected 15 clinical departments defect rate of med- ical record, and then using the repeated measures of SAS software to statistic these defect rate of medical record in last four years. Results The implementation of electronic medical record has led to slightly increasing of defect rate of medical record at the preliminary stage, the five mainly influence factors are listed below. The first one is intern doctors or refresher doctors came to our hospital in these years. Secondly, our doctors did not have the habit ,which is signature after printed the electronic medical record in time. Not-sign defects accounts for 28.5% of the proportion of the full year in 2012. Thirdly, some required medical information is blank which accounts for 22.1%. The forth one is electronic medical record has fully exposed the？defect, easy to find out which accounts for 13.4% in 2012, 8.3% in 2010 and 6.5% in 2009. The last one is the skills and range of quality control is continuously improve. Enhances the quality control of the anesthesia record, blood transfusion record, digestive endoscopy examination report, bronchoscopy report, etc. which accounts for 2.5%. Conclusion It is conduc- tive to the continuous improvement of the quality of medical records.

关 键 词：电子病案 病案缺陷 病案质量 影响因素 效果评价 

分 类 号：R197.3[医药卫生—卫生事业管理]