无纸化病案管理系统在出院病案管理中的应用效果评价  

Evaluation on the Application of Paperless Medical Record Management System in the Management of Discharged Hospital Records

作　　者：杨沛芝 张建林 Yang Peizhi;Zhang Jianlin(Department of Nephrology,Southern Theater General Hospital,Guangzhou 510010,Guangdong Province,China;不详)

机构地区：[1]南部战区总医院肾脏病科,广东省广州市510010

出　　处：《中国病案》2021年第12期8-10,共3页Chinese Medical Record

摘　　要：目的探讨无纸化病案管理系统使用前后在出院病案整理中的应用效果。方法随机抽取某院2019年1月1日-2019年12月30日100份出院病案,将其随机分为对照组和观察组各50例,比较2组护理文书整理、病案整理耗时,以及护士、医师、运送员、患者对无纸化病案系统满意度评价,以及比较使用1年后节约的纸张和打印耗材等成本。结果观察组护理文书整理时间(4.96±0.47)分钟低于对照组(9.96±0.73)分钟,P<0.05,观察组病案整理时间(3.50±0.48)分钟,低于对照组(13.99±0.90)分钟,P<0.05;无纸化病案管理系统使用前后满意度评价,护士由91.5%上升到98.1%,P<0.05,医师由89.8%上升到97.5%,P<0.05,运送员由93.5%上升到99.9,P<0.05,患者由91.5%上升到98.8%,P<0.05;使用1年节约纸张88491张和硒鼓30个。结论无纸化病案管理系统优化了出院病案的流程管理,实现了全流程的无纸化,增强了医疗信息化的建设,节约了成本,有效提高了医护人员的工作效率和患者的满意度。Objective To explore the difference of application effect of paperless medical records management system before and after using in the discharge medical records arrangement.Methods A hospital was randomly selected between January 1,2019 and December 30,2019.100 medical records of discharge,They were randomly divided into control group and observation group with 50 cases,The time changes of nursing documents and medical records were compared between the two groups.in each group.The control group did not use paperless medical records management system,the observation group used paperless management system.The time changes of nursing documents and medical records were compared between the two groups,And nurses,physicians,transporters,patients on the paperless medical record system satisfaction evaluation.Results The time of finishing nursing documents in the observation group(4.96±0.47)minutes was lower than that in the control group(9.96±0.73)minutes(P<0.05).The time of sorting out medical records in the observation group(3.50±0.48)minutes was lower than that in the control group(13.99±0.90)minutes(P<0.05).The satisfaction rate of nurses on the application effect of the system increased from 91.5% before use to 98.1%(P<0.05),Doctors’satisfaction with the application effect of the system increased to 97.5% from 89.8% before use(P<0.05),Transporters’satisfaction with the effectiveness of the system increased from 93.5% prior to use to 99.9%(P<0.05),Patient satisfaction with discharge increased from 91.5% to 98.8%(P<0.05);Use one year to save 88491 sheets of paper and 30 cartridges.Conclusion The paperless medical record management system optimizes the process management of discharged medical records,achieved a full process paperless,strengthen the construction of medical information,save the cost,greatly improve the working efficiency of medical staff and patient satisfaction.

关 键 词：无纸化病案管理系统 出院病案 流程优化 

分 类 号：R197.323[医药卫生—卫生事业管理]