围手术期环节质控对电子病历质量的影响  

Discussion on the Influence of Quality Control of Perioperative Links on the Quality of Electronic Medical Records

作　　者：陈少红[1] 陈海燕 冯雪梅 Chen Shaohong;Chen Haiyan;Feng Xuemei(Shenzhen Luohu District People's Hospital,Shenzhen 518000,Guangdong Province,China;不详)

机构地区：[1]深圳市罗湖区人民医院,广东省深圳市518000

出　　处：《中国病案》2020年第11期3-5,共3页Chinese Medical Record

摘　　要：目的探讨环节质控对围手术期电子病历质量的影响。方法选取3000份围手术期电子病历作为研究资料,2018年1月30日-2019年1月30日未实行环节质控1500份为A组,2019年2月28日-2020年2月28日实行环节质控的1500份为B组,比较2组时限性缺陷、书写性缺陷以及病历质量。结果B组术前1天查房、术前1天讨论、术前1天分析、手术当天风险评估表、手术当天安全核查表、术后8小时内完成手术记录、术后当天病程、术前相关检查等时限性缺陷的百分率分别为2.87%、1.40%、1.00%、1.27%、0.87%、1.33%、1.40%、1.20%;拷贝内容雷同、术前讨论无内涵、手术评估风险不足、手术记录不详尽、缺少知情文书、手术安全核查填写不全面等书写缺陷的发生率分别为13.60%、1.47%、1.20%、0.80%、0.40%、0.13%,均低于A组(P<0.05)。B组甲级病历率高于A组,差异有统计学意义。结论围手术期环节质控有利于提高电子病历的质量。Objective To explore the influence of link quality control on the quality of perioperative electronic medical records.Methods 3000 perioperative electronic medical records were selected as the research data.From January 30 th,2018 to January 30 th,2019,1500 copies without link quality control were group A,and 1500 copies of link quality control from February 28 th,2019 to February 28,2020 were group B.Compared the time limit defects,writing defects and medical records quality of the two groups.Results In group B,the percentage of time limit defects in ward rounds 1 day before surgery,discussion 1 day before surgery,analysis 1 day before surgery,risk assessment form on the day of surgery,safety check form on the day of surgery,surgical records completed within 8 hours after surgery,course of disease on the day of surgery,and preoperative relevant examinations were 2.87%,1.40%,1.00%,1.27%,0.87%,1.33%,1.40%,1.20%,respectively.The incidence of writing defects in identical copy content,uninformative preoperative discussion content,insufficient surgical evaluation risk,incomplete surgical records,lack of informed documents,and incomplete operation safety verificationwere 13.60%,1.47%,1.20%,0.80%,0.40%,and 0.13%,respectively,which were all lower than group A(P<0.05).The rate of class A medical record in group B was higher than that in group A.Conclusion Perioperative quality control was beneficial to improve the quality of electronic medical record.

关 键 词：围手术期 电子病历 环节质控 病历质量 时限性缺陷 书写性缺陷 

分 类 号：R197.323[医药卫生—卫生事业管理]