电子病历档案系统在医院病案标准化管理中的作用评价  

Evaluation of the Role of Electronic Medical Record File System in Standardized Management of Hospital Medical Records

作　　者：马文 MA Wen(The First Affiliated Hospital of Bengbu Medical College)

机构地区：[1]蚌埠医学院第一附属医院

出　　处：《中国标准化》2023年第12期224-227,共4页China Standardization

摘　　要：目的:分析医院病案标准化管理中应用电子病历档案系统的价值。方法:筛选60份病历作为样本进行本次研究,样本选自2020年1月-2022年1月,由研究人员在遵循随机原则下作随机分组处理,而后按照1:1的比例分组,对照组共计30例给予常规管理,观察组共计30例给予电子病历档案系统管理,对比2组管理效果、管理规范情况。结果:观察组管理效果高于对照组(P<0.05);观察组信息不完整(3.33%)、涂改(0.00%)、填写错误(3.33%)、缺页(0.00%)发生率低于对照组(P<0.05)。结论:在医院病案标准化管理中应用电子病历档案系统可缩短病历借阅时间及录入时间,避免出现病历信息不完整等问题,值得借鉴。Objective:To analyze the value of applying the electronic medical record file system in the standardized management of hospital medical records.Methods:60 medical records were selected as samples for this study.The samples were selected from January 2020 to January 2022,and the researchers were randomly divided into two groups according to the principle of randomization with the ratio of 1:1.The 30 cases in the control group were given routine management,and the 30 cases in the observation group were given the electronic medical record file system management.The management effect and management standard of the two groups were compared.Results:The management effect of the observation group was higher than that of the control group(P<0.05);the incidences of incomplete information(3.33%),correction(0.00%),filling errors(3.33%)and missing pages(0.00%)in the observation group were lower than those of the control group(P<0.05).Conclusion:The application of the electronic medical record file system in the standardized management of hospital medical records can not only shorten the borrowing time and input time of medical records,but also avoid problems such as incomplete medical record information,which is worthy of reference.

关 键 词：电子病历档案系统 医院 病案标准化管理 信息不完整 

分 类 号：R197.323[医药卫生—卫生事业管理]