基于信息化系统的院内会诊现状的实证分析与评价  

The Empirical Analysis and Evaluation of the Present Situation of the Hospital Consultation Based on the Information System

作　　者：程纯[1] 徐晓波[1] 杨柳[1] 焦翔[1] 张少明[1] Cheng Chun Xu Xiaobo Yang Liu Jiao Xiang Zhang Shaoming(The Ninth People＇s Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200011, China)

机构地区：[1]上海交通大学医学院附属第九人民医院,上海市200011

出　　处：《中国病案》2016年第12期29-32,共4页Chinese Medical Record

摘　　要：目的通过信息化会诊系统分析某三级甲等医院院内会诊的现状。方法通过院内电子会诊系统分析2015年第一季度该院院内会诊情况,并抽查同时段会诊相关病案300份,了解会诊病历的书写质量。结果第一季度院内会诊总数为2613例,会诊科室前二位分别是心内科和神经内科,其中急会诊为1175例,占44.96%,平会诊为1345例,占51.47%,会诊质量欠佳原因,主要为急会诊10分钟未到达12例,占0.9%,申请科室未掌握急会诊指针26例,占2.1%,会诊医师资质不够11例,占0.7%。会诊病历质量欠佳原因主要为基本信息不完善6例,占2.0%,主要住院经过未写14例,占4.7%,诊断未写或未写全7例,占2.3%,会诊目的未写11例,占3.7%,病程记录未反映会诊意见12例,占4.0%。结论院内会诊是关系到医疗质量和医疗安全的重要诊疗手段,随着医院总体业务量的上升,院内会诊的总量也较大,但在会诊过程及会诊病史书写上均存在着影响会诊质量的问题,为医疗安全留下了隐患,医务管理部门及各级医师都要高度重视,才能提高会诊质量,保障医疗安全。Objective To analyze the status of a three level of first-class hospital hospital consultation information consultation system. Methods In the first quarter of 2015, the hospital consultation system was analyzed through the hospital electronic consultation system, and 300 copies of the relevant medical records were analyzed and the quality of the medical records were understood. Results For the first quarter total number of hospital consultation for 2613 patients, the consultation department before the two are Department of Cardiology and neurology, the urgent consultation for 1175 cases, accounted for 44.96%, flat consuhation for 1345 cases, accounting for 51.47%, the reason for the poor quality of the consultation, mainly for emergency consultation for 10 minutes did not reach 12 cases, accounted for 0.9%, application department fails to grasp the urgent consultation pointer in 26 cases, accounted for 2.1%, physician consuhation qualification is not enough in 11 cases, accounting for 0.7%. Consultation history of poor quality reasons mainly for basic information is not perfect in 6 cases, 2.0%, mainly in hospital after write in 14 cases, accounted for 4.7%, diagnosis did not write or not to write 7 cases, accounted for 2.3%, consultation is not written in 11 cases, accounted for 3.7%, course record does not reflect the consultant＇s opinion in 12 cases of 4.0%. Conclusion Hospital consultation is an important diagnostic and therapeutic means related to the medical quality and medical safety, with the rising volume of services in general hospitals, hospital consultation of the total is also larger, but in the consultation process and consultation to write a history of there are problems affecting the quality of consultation, medical safety left hidden trouble, medical management departments at all levels and physicians should attach great importance to, in order to improve the quality of the consultation, to protect the safety of medical treatment.

关 键 词：院内会诊 信息化 医疗质量 

分 类 号：R197.323[医药卫生—卫生事业管理]