探讨电子病历的实施对病案管理和患者的影响  

Influence of the Implementation of Electronic Medical Records on Medical Record Management and Patients

作　　者：葛冬娜[1] 袁蕊[1] Ge Dongna;Yuan Rui(Department of Medical Records and Statistics,Beijing Jishuitan Hospital,Beijing 10035,China;不详)

机构地区：[1]北京积水潭医院病案统计科,北京市100035

出　　处：《中国病案》2020年第12期10-13,共4页Chinese Medical Record

摘　　要：目的分析电子病历的实施对病案管理和患者病案复印的影响。方法选取某院2019年2月1日-2019年4月30日期间的16775份实施急诊电子病历前的纸质病案进行统计,选取2019年10月8日-2020年1月5日内的3010份病案作为急诊电子病历实施后的病案进行比较,分析患者复印急诊病案的情况。再根据每日出院病案的回收,整理,装订,归档工作的现有情况进行分析,对比电子病历在急诊病案和住院病案两部分管理工作中的优势和不足。结果电子病历实施前共回收纸质病案16775份,共48907页,平均每天188份,平均每天550页。电子病历实施后只需要回收少数有医师和患者签名的内容,纸质病案回收数量明显下降,共回收3010份,13421页,每天平均34份,151页。比之前每天回收减少154份,下降81.91%;电子病历实施前患者复印急诊病案的等待时间平均为(3.00±0.92)分钟,实施后等候时间明显减少,平均为(2.15±0.81)分钟,P=0.004,差异有统计学意义,电子病历的实施大大减少了患者复印排队时间,提高了患者复印的满意度。结论电子病历有效降低病案纸质成本,节省病案存储空间,提高了病案管理人员的工作效率,缩短了患者复印等候时间。Objective To analyze the impact of electronic medical records on medical record management and patients.Methods A total of 16775 medical records from February 1 to April 30,2019 before the implementation of emergency electronic medical record and 3010 medical records from October 8,2019 to January 5,2020 after the implementation of electronic medical record in the hospital were selected for statistical comparison.Then,according to the current situation of the recovery,sorting,binding and filing of daily discharge medical records,the advantages and disadvantages of electronic medical record in medical record management are discussed.Results Before the implementation of electronic medical records has recycled paper 16775 copies,48907 pages,with an average of 188 per day and 550 pages per day.After the implementation of electronic medical records,only a few contents signed by doctors and patients need to be recovered,and the number decreased obviously,with a total of 3010 copies,13421 pages,an average of 34 copies per day,and an average of 151 pages per day.Compared with the previous day,there were 154 fewer medical records per day,a decrease of 81.91%.Visible electronic medical records significantly save the warehouse storage space,improve the efficiency of the personnel records recycling;The average waiting time for patients to copy emergency medical records was 3.00±0.92 min before the implementation of electronic medical records,the waiting time is visibly reduced after the implementation,and the average waiting time was 2.15±0.81 min after the implementation of electronic medical records,P=0.004,with a statistically significant difference.The implementation of electronic medical records greatly reduced the queuing time for patients to copy and improved the satisfaction of patients to copy.Conclusion Electronic medical records have effectively reduced the paper cost of medical records,saved the storage space of medical records,improved the work efficiency of medical record managers,and shortened the waiting ti

关 键 词：电子病历 无纸化 急诊 病案管理 

分 类 号：R197.323[医药卫生—卫生事业管理]