移动软件系统在精神专科医院电子病历管理中的应用  

Application of Mobile Software System in Electronic Medical Records Management of Psychiatric Hospitals

作　　者：陈贝[1] 李彪[1] 台勇 叶萌[1] Chen Bei;Li Biao;Tai Yong;Ye Meng(Wuhan Mental Health Center,Wuhan 430012,Hubei Province,China;不详)

机构地区：[1]武汉市精神卫生中心,湖北省武汉市430012 [2]温州市康宁医院精神科,浙江省温州市325000

出　　处：《中国病案》2021年第9期32-33,90,共3页Chinese Medical Record

摘　　要：目的探讨移动软件系统在精神专科医院电子病历管理中的应用价值,为提高病案管理质量提供参考。方法某院从2019年1月1日开始实施移动软件系统化病案管理,选取实施前2018年1月1日-2018年12月31日1100份传统纸质化病案管理资料以及实施后2019年1月1日-2019年12月31日1100份移动软件系统化病案管理资料,比较实施前后合格病案比例、病案缺陷情况、归档情况、调阅情况。结果实施后精神科病案质量等级优于实施前,Ⅰ级合格病案比例为88.73%高于实施前72.45%;实施后精神科病案病历书写主要缺陷中入院记录、病程记录、书写基本要求、知情同意书、辅助检查、病案首页、出院记录缺陷发生率2.82%、2.36%、3.09%、0.55%、1.73%、3.73%、1.73%低于实施前7.73%、7.278%、18.73%、2.18%、3.27%、17.00%、5.18%;实施后病案3日归档和7日归档率分别为97.27%、99.55%高于实施前70.64%、91.27%;实施后病案调阅平均时间、病案复印或打印平均时间均短于实施前。结论移动软件系统下的电子病案管理提高了精神科病案合格率,减少了病例书写缺陷,提高了病案归档效率。Objectives To explore the application value of mobile software system in electronic medical records management of psychiatric hospitals,so as to provide reference for improving quality of medical records management.Methods A hospital began to implement mobile software systematic medical record management on January 1st,2019.1100 traditional paper-based medical record management materials from January 1st,2018 to December 31st,2018 before implementation and 1100 mobile software systematic medical record management materials from January 1st,2019 to December 31st,2019 after implementation were selected.The proportion of qualified medical records,the defects of medical records,the filing of medical records and the retrieval of medical records before and after implementation were compared.Results After implementation,the quality of psychiatric medical records was better than that before implementation,and proportion of grade-I qualified medical records was higher than that before implementation(88.73%vs 72.45%).After implementation,incidence rates of main defects in psychiatric medical records writing such as admission records,course records,basic writing requirements,informed consent form,auxiliary examination,medical record homepage,and discharge records were 2.82%,2.36%,3.09%,0.55%,1.73%,3.73%and 1.73%,lower than 7.73%,7.278%,18.73%,2.18%,3.27%,17.00%and 5.18%before implementation.After implementation,archiving rates of medical records within 3d and 7d were 97.27%and 99.55%,higher than 70.64%and 91.27%before implementation.After implementation,average time of medical records querying,and average time of medical records copying or printing were shorter than those before implementation.Conclusions The electronic medical records management under mobile software system could increase qualification rate of psychiatric medical records,reduce the defects of case writing,improve archiving efficiency of medical records.

关 键 词：精神专科医院 电子病案管理 移动软件系统 应用价值 

分 类 号：R197.323[医药卫生—卫生事业管理]