病历阅改在护理电子病历质控中的效果评价  

Effect Evaluation of Medical Record Reading and Correcting in Quality Control of Nursing Electronic Medical Record

作　　者：阎忠琴 YAN Zhongqin(Department of Medical Record Management,Yantai Mountain Hospital,Yantai,Shandong Province,264001 China)

机构地区：[1]烟台市烟台山医院病案管理科,山东烟台264001

出　　处：《中国卫生产业》2023年第4期88-91,共4页China Health Industry

摘　　要：目的分析护理电子病历质控中应用病历阅改的有效性。方法选取烟台市烟台山医院16名护士作为研究对象,将2021年10月—2022年10月期间电子病历1200份作为研究组,采用病历阅改管理;将2020年9月—2021年9月期间电子病历1200份作为参照组,采用传统管理。分析不同管理方式的效果。结果研究组护理记录(96.12±1.05)分、体温单(96.36±2.05)分、首次护理记录(96.05±1.23)分和医嘱单评分(97.02±1.23)分高于参照组,差异有统计学意义(P<0.05)。与参照组相比,研究组首次护理记录内容漏项(0.42%)、病情与要求不相符(0.58%)、未进行专科观察(0.42%)、护理记录缺乏连贯性(0.17%)、护理措施未能有效落实(0.25%)、缺乏病情记录(0.42%)、缺乏护理反馈发生率(0.33%)更低,差异有统计学意义(P<0.05)。研究组护理人员差错规避(95.46±2.05)分、护理电子病历质控准确性(95.63±2.05)分和质控耗时等评分(94.96±2.31)分高于参照组,差异有统计学意义(P<0.05)。结论病历阅改在护理电子病历质控中效果突出,可以提高护理电子病历质控管理效果,值得推广。Objective To analyze the effectiveness of medical record reading in nursing electronic medical record quality control.Methods 16 nurses from Yantai Mountain Hospital were selected as the research subjects,1200 electronic medical records from October 2021 to October 2022 were selected as the study group,medical records modification management was adopted,1200 electronic medical records from September 2020 to September 2021 were selected as the reference group,traditional management was adopted.Analyzed the effects of different management styles.Results The nursing record(96.12±1.05)points,body temperature record(96.36±2.05)points,first nursing record(96.05±1.23)points and doctor´s order score(97.02±1.23)points in the study group were higher than those in the reference group,the difference was statistically significant(P<0.05).Compared to the reference group,the missing contents of the first nursing record(0.42%),inconformity of the condition with the requirements(0.58%),no specialist observation(0.42%),lack of consistency of nursing records(0.17%),ineffective implementation of nursing measures(0.25%),lack of medical record(0.42%),the incidence of lack of nursing feedback(0.33%)in the study group was lower,the difference was statistically significant(P<0.05).The scores of error avoidance(95.46±2.05)points,accuracy of quality control of nursing electronic medical record(95.63±2.05)points and quality control time(94.96±2.31)points in the study group were higher than those in the reference group,the difference was statistically significant(P<0.05).Conclusion The effect of reading and correcting medical records is prominent in the quality control of nursing electronic medical records,which can improve the quality control management effect of nursing electronic medical records.It is worth promoting.

关 键 词：病历阅改 电子病历 质量控制 效果评价 

分 类 号：R19[医药卫生—卫生事业管理]