胸部肿瘤外科电子病历书写质量及常见问题分析  

Analysis of the quality and common problems of electronic medical records in the department of thoracic tumor surgery

作　　者：张倩 刘蕴瑶 张晓莉 马箐 赵格非 马山蕊 方安[4] 赵亮 ZHANG Qian;LIU Yunyao;ZHANG Xiaoli;MA Qing;ZHAO Gefei;MA Shanrui;FANG An;ZHAO Liang(Clinical Epidemiology and EBM Unit,National Clinical Research Center for Digestive Diseases,Beijing Friendship Hospital,Capital Medical University,Beijing 100050,China;Department of Finance and Accounting,University of Science and Technology Beijing,Beijing 100083,China;Department of Thoracic Surgery,National Cancer Center / National Clinical Research Center for Cancer / Cancer Hospital,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100021,China;Institute of Medical Information,Chinese Academy of Medical Sciences and Peking Union Medical College,Beijing 100020,China)

机构地区：[1]首都医科大学附属北京友谊医院国家消化系统疾病临床医学研究中心,北京100050 [2]北京科技大学财务与会计系,北京100083 [3]国家癌症中心/国家肿瘤临床医学研究中心/中国医学科学院北京协和医学院肿瘤医院胸外科,北京100021 [4]中国医学科学院医学信息研究所,北京1000200

出　　处：《癌症进展》2019年第1期97-100,共4页Oncology Progress

基　　金：中国医学科学院医学与健康科技创新工程协同创新团队项目(2017-I2M-3-014)

摘　　要：目的分析肿瘤外科电子病历质量缺陷及其原因,探讨提高电子病历质量的对策。方法采用随机抽样法随机选取中国医学科学院肿瘤医院胸部肿瘤外科518份未出院患者的电子病历,按《病历书写基本规范》和《电子病历应用管理规范(试行)》的要求进行质控。结果 518份电子病历中,共有76份(14.67%)电子病历存在质量缺陷,其中雷同错误和输入类错误最多,错误率分别为39.47%和21.05%,其次是数字类错误、病灶部位描述错误及体格检查记录描述不一致,错误率分别为17.11%、14.47%、10.53%。结论目前科室医师背景复杂、流动性强,加强医师电子病历书写的培训和指导力度,以及法制观念,是提高病历书写质量的关键。Objective To analyze the quality defects and causes in electronic medical records in the department of thoracic tumor surgery and discuss the countermeasures to improve the quality of medical records.Method 518 electronic medical records of undischarged patients in thoracic tumor surgery department of Cancer Hospital Chinese Academy of Medical Sciences,were randomly selected,to carry out quality control according to the requirements of Basic Standard for Medical Record Writing and Standards for the Management of Electronic Medical Records(Trial).Result Of the 518 medical records,a total of 76(14.67%)records had writing problems,of which the duplications and input errors were the most,accounting for 39.47%and 21.05%,respectively,followed by numerical errors,false descriptions of lesions,and inconsistent descriptions of physical examination records,with proportions being 17.11%,14.47%,10.53%,respectively.Conclusion At present,the physicians in the department are of complex background and are highly mobile,therefore strengthening the training and guidance of physicians’electronic medical record writing,as well as the legal concept,is the key to improving the quality of medical records.

关 键 词：电子病历 胸部肿瘤外科 电子病历质量 

分 类 号：R197.324[医药卫生—卫生事业管理]