电子病案数字翻拍在医院档案管理工作中的应用  

Application of Digital Reproduction of Electronic Medical Records in Hospital Archives Management

作　　者：古力米热·买买提 Gulimire·Maimaiti(Medical Quality and Safety Management Center,Korla Hospital of the Second Division of Xinjiang Production and Construction Corps,Korla 841000,Xinjiang,China)

机构地区：[1]新疆生产建设兵团第二师库尔勒医院医疗质量与安全管理中心,新疆库尔勒841000

出　　处：《医学信息》2024年第2期77-80,共4页Journal of Medical Information

摘　　要：目的分析电子病案数字翻拍管理方法在医院档案管理工作中的应用效果。方法选取新疆生产建设兵团第二师库尔勒医院自2020年8月-2022年8月病案管理相关临床资料作为研究对象,按照时间顺序将2020年8月-2021年8月实施电子病案纸质管理设为对照组,2021年9月-2022年8月给予电子病案数字翻拍管理方法设为观察组。比较两组病历管理的质量、医院档案管理人员满意度及对管理办法的相关知识认知程度。结果观察组电子病案存在缺陷病历、表格或记录单存在漏项、错别字及生命体征绘制与实际情况不符、诊疗记录不规范、医护记录不一致、各项评估量表、同意书欠签名等不良管理事件发生率低于对照组,差异有统计学意义(P<0.05)。观察组医院档案管理人员满意度量表评分及医院档案管理人员知识认知程度评分高于对照组,差异有统计学意义(P<0.05)。结论电子病案数字翻拍管理方法的应用可提高病历管理质量、医院档案管理人员对管理工作的满意度以及相关知识的认知度。Objective To analyze the application effect of digital reproduction of electronic medical records in hospital archives management.Methods Clinical data related to medical record management in Korla Hospital of the Second Division of Xinjiang Production and Construction Corps from August 2020 to August 2022 were selected as clinical data,and the control group was selected in chronological order(August 2020 to August 2021).According to the time sequence,the digital reproduction of electronic medical records from August 2020 to August 2021 was set as the control group,and the digital remake management method of electronic medical records from September 2021 to August 2022 was set as the observation group.The quality of medical record management,the satisfaction of hospital archives management personnel and the knowledge of management methods were compared between the two groups.Results The incidence of adverse management events in the observation group was lower than that in the control group,such as defective medical records,forms or record sheets,missing items,misspellings,inconsistencies in the drawing of vital signs,non-standard diagnosis and treatment records,inconsistent medical records,various evaluation scales,undersignature of consent forms,etc.,the difference was statistically significant(P<0.05).The satisfaction scale score of hospital archives managers and the knowledge cognition degree score of hospital archives managers in the observation group were higher than those in the control group,and the difference was statistically significant(P<0.05).Conclusion The application of digital reproduction of electronic medical records method can improve the quality of medical record management,the satisfaction of hospital archives managers to management work and the recognition of related knowledge.

关 键 词：电子病案管理 医院档案管理 满意度 

分 类 号：R197.323[医药卫生—卫生事业管理] G271[医药卫生—公共卫生与预防医学]