电子病历与手写病历质量比较  

Quality Comparison between Electronic Medical Records and Handwritten Medical Records

作　　者：贾晓燕[1] 周宏久[1] 陈丽娟[1] 李东敏[1] 

机构地区：[1]广东医学院附属医院病案室,湛江市524001

出　　处：《中国病案》2013年第12期11-13,共3页Chinese Medical Record

摘　　要：目的通过比较我院电子病历与手写病历质量,明确电子病历在提高医疗质量中的作用,更好的服务临床工作。方法随机选取2013年广东医学院附属医院出院电子病历2000份作为实验组,2012年手写病历2000份为对照组,比较两组病历缺陷项目、缺陷数、平均住院病历评分值及甲级病历率;结果实验组住院病历缺陷数明显低于对照组,常见缺项项目包括:三级医师查房雷同、未按时完成记录、诊断欠规范、病案首页填写不完整、签名不及时或漏签名等;平均住院病历评分值及甲级病历率明显高于对照组,差异有统计学意义(P<0.05)。结论电子住院病历质量明显高于纸质病历,值得推广应用。Objective To compare the quality between electronic medical records and handwritten medical records,investigate the role of electronic medical records in the improvement of the medical treatment quality, and make service for the clinical work better. Methods 2000 cases of electronic medical records from the affiliated hospital of Guangdong Medical College in 20 l 3 were randomly selected as the experimental group, and 2000 cases of handwritten medical records in 2012 as the control group. Then compared the defect items and numbers, mean medical records evaluation score and records grade tale between the two groups. Results The defects number in medical records of experimental group was lower than the control group significantly, and the common defects were identical three physician rounds, failure to complete the recording timely, less standardized of diagnosis, incomplete filling of home pages, not timely signature or missing signatures. The mean medical record evaluation score and records grade rate in experimental group were better than that in control group, and there were statistically significant between two groups （P 〈 0.05 ）. Conclusions The quality of electronic medical records was better than the handwritten medical records, and should be widely popularization and application.

关 键 词：电子病历 手写病历 质量 

分 类 号：R197.3[医药卫生—卫生事业管理]