电子病案首页缺陷分析及其干预对策研究  

Analysis of electronic medical record homepage defect and its intervention measures

作　　者：罗小丽 沈炽强 王素芬 张扬文 LUO Xiao-li SHEN Chi-qiang WANG Su-fen(Department of Information,Guangzhou City Zengcheng District People＇s Hospita)

机构地区：[1]广州市增城区人民医院信息科(病案室),511300

出　　处：《中国实用医药》2017年第26期189-191,共3页China Practical Medicine

摘　　要：目的研究分析电子病案首页缺陷的原因及相应干预对策。方法选取出院患者的1600份电子病案作为研究对象。将未采用干预措施的800份作为对照组,将采用干预措施的800份作为观察组。以相关法律法规为依据,对两组电子病案首页缺陷内容进行归类、统计、对比,同时根据比较结果分析首页缺陷原因。结果对照组800份病案中,缺陷病案220份,缺陷率27.50%;观察组800份病案中,缺陷病案55份,缺陷率6.88%;两组比较差异具有统计学意义(P<0.05)。按缺陷项目统计各项信息显示,两组病案缺陷率排列前三位的均是基本信息错误、疾病诊断选择错误、入院病情判别错误。观察组各项缺陷项目信息的缺陷率均低于对照组,差异具有统计学意义(P<0.05)。结论将建立病案质量控制体系、加强质量管理、加强病案首页填报培训、增强临床医师责任心等干预措施应用于电子病案首页填写中,可以有效控制缺陷率。Objective To study and analyze the causes of electronic medical record homepage defect and its corresponding intervention measures. Methods A total of 1600 electronic medical records of discharged patients as study subjects. There were 800 records without intervention measures as control group, and 800 records with intervention measures as observation group. On the basis of relevant laws and regulations, the content of electronic medical record homepage defect were classified, counted and compared, and the reasons of homepage defects were analyzed according to the comparison results. Results The control group had 220 defective records, with defective rate as 27.50%, while the observation group had 55 defect records, with defect rate as 6.88%. Their difference was statistically significant（P〈0.05）. According to the statistics of defect items, the top three of the two groups were basic information error, disease diagnosis error and hospital condition discrimination error. The observation group had lower defect rate of defective project information than the control group, and the difference was statistically significant（P〈0.05）. Conclusion Application of intervention measures, such as establishment of medical record quality control system, strengthening quality management, strengthening homepage filling training and enhancement of clinician＇s sense of responsibility, can effectively control defect rate.

关 键 词：电子病案 首页填写 缺陷分析 

分 类 号：R197.323[医药卫生—卫生事业管理]