电子病历对病案回收效率及病案首页数据质量的影响  

The effect of electronic medical records on the recovery efficiency of medical records and the data quality of medical records home page

作　　者：韦新理 赖文[1] 余艳[1] 吴光莲 张伟琴[1] 牙丽绵 WEI Xinli;LAI Wen;YU Yan;WU Guanglian;ZHANG Weiqin;YA Limian(Department of Medical Record,Jiangbin Hospital of Guangxi Zhuang Autonomous Region,Nanning 530021,China)

机构地区：[1]广西壮族自治区江滨医院病案室,广西南宁530021

出　　处：《中国现代医生》2019年第1期125-128,共4页China Modern Doctor

摘　　要：目的探讨电子病历对病案回收效率及病案首页质量的影响,为电子病历的推广提供参考。方法回顾性分析广西某三甲医院实施电子病历前(2011年1月1日～12月31日)、后(2012年1月1日～12月31日)所有临床科室的病案回收数量、回收率、平均回收时间,从完整性、逻辑性、规范性3个维度对实施电子病历前后2个时段病案首页数据质量进行评估。结果实施电子病历后2、3、7个工作日回收率分别由23.78%提高到42.45%、由38.17%提高到56.55%、由86.12%提高到92.75%(P=0.000),平均回收时间由(4.50±1.50)d降低至(3.42±1.10)d,差异具有统计学意义(t=33.118,P=0.000)。应用电子病历后病案首页项目完整率、规范率和逻辑符合率明显优于应用电子病历前。结论电子病历明显提高病案回收率,提高病案首页质量,值得医院推广。Objective To explore the influence of electronic medical records on the recovery efficiency of medical records and the quality of medical records,and to provide reference for the promotion of electronic medical records.Methods The recovery quantity,recovery rate,and average recovery time of medical records in a top three hospital in Guangxi before(from January 1 to December 31,2011)and after the implementation of the electronic medical records(from January 1 to December 31,2012)were retrospective analyzed.The data quality of the home page of the medical records during the two periods before and after the implementation of the electronic medical records were evaluated from the three dimensions of integrity,logic and normativeness.Results The recovery rate of 2,3,and 7 working days after the implementation of electronic medical records increased from 23.78%to 42.45%,from 38.17%to 56.55%,from 86.12%to 92.75%(P=0.000).And the average recovery time decreased from(4.50±1.40)days to(3.42±1.10)days,and the difference was statistically significant(t=33.118,P=0.000).After the application of the electronic medical record,the complete rate,standardization rate and logical compliance rate of the home page of the medical record were obviously superior to those before the application of the electronic medical record.Conclusion Electronic medical records can significantly improve the recovery rate of medical records and improve the quality of medical records.It is worthy of hospital promotion.

关 键 词：电子病历 病案回收 病案首页 数据质量 

分 类 号：R197.3[医药卫生—卫生事业管理]