手术麻醉信息系统对麻醉文书质量的影响  

Effect of Anesthesia Information Management System on the Anesthesia Document

作　　者：何伟[1] 王涛[1] 马艳凯[1] 马云娜[1] 

机构地区：[1]河北省人民医院,石家庄市050051

出　　处：《中国病案》2018年第1期37-39,共3页Chinese Medical Record

基　　金：河北省卫生计生委(20170215)

摘　　要：目的探讨手术麻醉信息系统对麻醉文书书写质量的影响。方法随机抽取2015年7月-2015年12实施手术治疗的终末病案以及2017年1月-2017年6月实行手术麻醉信息系统后的手术病案各2000份,按照原卫生部制定的《病历书写基本规范》对两个阶段病历的麻醉文书进行检查评估,针对麻醉文书合格率、缺陷等数据进行统计分析。结果 2017年1月-6月较2015年7月-12月麻醉文书合格率升高60.5%,11项缺陷均下降,其中9项有统计学意义(P<0.01),2项无统计学意义(P>0.05)。结论手术麻醉信息系统的实施明显提高围手术期病案中麻醉文书的书写质量。Objective To explore the effect of anesthesia information management system on the anesthesia document. Methods To extract randomly 2000 terminal medical records about surgical operation from July to December in 2015, and 2000 terminal medical records about surgical operation from January to June in 2017 after the application of anesthesia information management system, then conducted examination and assessment on the two stages of anesthesia documents according to the basic criterion of medical records writing announced by the Health Ministry, and made statistics analysis on the data included qualified rate and defects. Results Compared with the anesthesia documents from July to December in 2015, the qualified rate of the documents from January to June in 2017 raised 60. 5%, 11 defects decreased, in which 9 defects had statistical significance （P〈0. 01）, and 2 defects had no statistical significance （P〉0. 05）. Conclusions The application of anesthesia information management system significantly improved the writing quality of perioperative anesthesia document.

关 键 词：手术麻醉信息系统 电子病历 麻醉文书 质量 

分 类 号：R197.323[医药卫生—卫生事业管理]