无纸化病案管理系统应用在病案管理中的效果分析  

Analysis of the effect of paperless medical record management system in medical record management

作　　者：崔亚萍[1] Cui Yaping(Jiangsu Provincial Cancer Hospital(Jiangsu Institute of Cancer Prevention and Treatment,Affiliated Cancer Hospital of Nanjing Medical University),Nanjing,Jiangsu 210009,China)

机构地区：[1]江苏省肿瘤医院(江苏省肿瘤防治研究所,南京医科大学附属肿瘤医院),江苏南京210009

出　　处：《首都食品与医药》2024年第4期110-113,共4页Capital Food Medicine

摘　　要：目的 分析在病案管理中采取无纸化病案管理系统的价值.方法 选取江苏省肿瘤医院在无纸化病案管理系统实施前后管理的600份病案,根据病案管理时间进行分组处理,将2020年1月-2020年12月管理的300份分在比较组,采用纸质病案管理,将2021年1月-2021年12月管理的300份纳入研究组,应用无纸化病案管理系统,对比组间差错事件、病案复印和调阅时间、管理质量和满意度.结果 研究组差错事件发生率低于比较组;比较组病案复印和调阅时间相比于研究组较长;研究组管理质量明显高于比较组;比较组满意度低于研究组,差异存在统计学意义(P<0.05).结论 在病案管理中应用无纸化病案管理系统,可以减少差错事件,提高病案使用效率,对于管理质量和满意度的提高也有着积极影响.Objective To observe the value of paperless medical record management system in medical record management.Methods Selecting 600 medical records managed by Jiangsu Provincial Cancer Hospital before and after the implementation of the paperless medical record management system,grouping them according to the time of medical record management.The 300 records managed from January 2020 to December 2020 were divided into a comparison group,and paper medical record management was used.The 300 records managed from January 2021 to December 2021 were included in the study group,and the paperless medical record management system was used to compare inter group error events,medical record copying and retrieval time,manage quality and satisfaction.Results The incidence of error events in the study group was lower than that in the comparison group.Compared with the study group,the time for copying and retrieving medical records in the comparison group was longer.The management quality of the study group was significantly higher than that of the comparison group.The satisfaction of the comparison group was lower than that of the study group,and the difference was statistically significant(P<0.05).Conclusion The application of paperless medical record management system in medical record management can reduce error events,improve the efficiency of medical record use,and have a positive impact on the improvement of management quality and satisfaction.

关 键 词：病案管理 无纸化病案管理系统 管理效果 

分 类 号：R197.323[医药卫生—卫生事业管理]