纸质与电子病案双轨制模式下的病案管理效果评价  

Evaluation on the effect of medical record management under the dual-track system of paper and electronic medical records

作　　者：康国 王玉珍[1] Kang Guo;Wang Yuzhen(Department of Pediatrics,Maternal and Child Health Hospital of Tangshan,Tangshan 063000,Hebei Province,China;不详)

机构地区：[1]唐山市妇幼保健院,河北省唐山市063000

出　　处：《中国病案》2023年第7期10-13,共4页Chinese Medical Record

摘　　要：目的分析纸质与电子病案并存的双轨制模式下病案管理对病案复印效率、查找与浏览时间、管理质量及医护人员知晓率与满意度的影响。方法将2020年1月1日-2020年6月30日采取传统纸质病案管理的1438份病案划分为对照组,将2020年7月1日-2020年12月31日采取纸质病案与电子病案并存的双轨制模式管理的1456份病案划分为观察组,比较两组病案复印效率相关指标、病案查找与浏览花费时间、病案归档错漏率及医护人员知晓率与满意度。结果观察组病案复印时间(8.58±1.64)分钟明显短于对照组病案复印时间(12.33±2.41)分钟(P<0.05),观察组复印页数(3436.86±70.24)页/天明显多于对照组复印页数(2573.39±61.31)页/天,差异比较均有显著性(P<0.05);观察组病案查找时间(1.12±0.17)分钟和病案浏览时间(2.35±1.36)分钟均明显短于对照组病案查找时间(8.34±0.58)分钟和病案浏览时间(12.71±2.65)分钟,差异比较均有显著性(P<0.05);观察组病案内容缺失、资料错误、病案损坏、病案丢失等归档错漏情况总发生率为0.55%,对照组为2.43%,差异比较有统计学意义(P<0.05);观察组医护人员对病案管理知识的知晓率评分(91.17±2.29)分和对病案管理工作满意度评分(92.53±2.60)分均明显高于对照组知晓率评分(73.35±4.84)分和满意度评(79.83±3.46)粉,差异比较均有显著性(P<0.05)。结论在病案科病案管理中应用双轨制模式能有效提高复印效率,缩短病案查找与浏览所需时间,还可显著降低病案归档错漏率,有利于促进病案管理质量的提升,增加医护人员对病案管理的知晓率与满意度。Objectives This study aims to analyze the effect of medical record management under the dual-track system of paper and electronic medical records on the copying efficiency of medical records,search and browsing time,management quality,awareness rate,and satisfaction of medical staff.Methods 1,438 medical records with traditional paper medical record management from January 1,2020 to June 30,2020 were included in the control group,and 1,456 medical records managed by the"dual-track system"model of the paper medical record and electronic medical record from July 1,2020 to December 31,2020 were included in the observation group.The related indicators of the efficiency of medical records copying,the time spent on medical record search and retrieval,the error rate of medical record filing,and the awareness rate and satisfaction of medical staff were compared between the two groups.Results The copying time of medical records in the observation group(8.58±1.64 minutes)was significantly shorter than that of the control group(12.33±2.41 minutes,P<0.05).The number of copied pages in the observation group(3436.86±70.24 pages/day)was significantly more than that in the control group(2573.39±61.31 pages/day),and the difference was significant(P<0.05).The search time of medical records(1.12±0.17 minutes)and browsing time of medical records(2.35±1.36 minutes)in the observation group were significantly shorter than the search time of medical records(8.34±0.58 minutes)and browsing time of medical records(12.71±2.65 minutes)in the control group.The differences were all significant(P<0.05).The total incidence of filing errors and omissions such as lack of medical record content,data error,medical record damage,and medical record loss in the observation group was 0.55%,compared with 2.43%in the control group,and the difference was statistically significant(P<0.05).The awareness rate score(91.17±2.29)and the satisfaction score(92.53±2.60)of medical record management knowledge in the observation group were significantly high

关 键 词：双轨制模式 病案科 病案管理 应用效果 满意度 

分 类 号：R197.323[医药卫生—卫生事业管理]