四川省医疗机构门诊电子病历应用现状分析  

Analysis of the Current Situation of Outpatient Electronic Medical Records in Medical Institutions in Sichuan Province

作　　者：郭媛 陈励耘[2] 张娟 唐欣[2] 赖世春 王金秋 万智 Guo Yuan;Chen Liyun;Zhang Juan;Tang Xin;Lai Shichun;Wang Jinqiu;Wan Zhi(West China School of Nursing,Sichuan University,Chengdu 610041,China;Outpatient Department of West China Hospital,Sichuan University,Chengdu 610041,China;Sichuan Provincial Outpatient Management Medical Quality Control Center,Chengdu 610041,China)

机构地区：[1]四川大学华西护理学院,成都610041 [2]四川大学华西医院门诊部,成都610041 [3]四川省门诊管理医疗质量控制中心,成都610041

出　　处：《成都医学院学报》2024年第2期334-338,共5页Journal of Chengdu Medical College

基　　金：四川省医学会医学科研课题计划(No:S22091)。

摘　　要：目的 了解四川省医疗机构门诊电子病历的应用现状,分析进一步提升门诊电子病历建设与管理水平的措施。方法 采用分层整群随机抽样的方法于2023年9月对四川省155家二级及以上应用门诊电子病历的医疗机构进行调查,调查内容包括医疗机构基本情况、门诊电子病历建设与管理情况。结果 155家医疗机构中,三级和二级医疗机构分别为107家(69.03%)和48家(30.97%),全面应用和部分应用门诊电子病历的医疗机构分别为142家(91.61%)和13家(8.39%),采用半结构化电子病历模板95家(61.29%)。检验、超声、影像、病理报告、历史病历能直接引用的分别为141家(90.97%)、133家(85.81%)、127家(81.94%)、61家(39.35%)、 92家(59.35%)。使用门诊标准诊断库/医保诊断的有151家(97.42%)。新上门诊医生开展病历相关培训共144家(92.90%),有专业技术人员系统维护的有149家(96.13%),为专家配置专职或兼职医生助理共53家(34.19%),诊间提供语音录入、图像提取等辅助设施的有11家(7.10%)。结论 各级医疗机构在门诊电子病历建设与管理方面存在一定差异,门诊病历的信息化水平参差不齐。医疗机构需进一步提升门诊电子病历的建设与管理水平。Objective The aim of this study is to investigate the current situation of outpatient electronic medical record(EMR)application in medical institutions in Sichuan Province,and analyze measures to further enhance the level of outpatient EMR construction and management.Methods In September 2023,a total of 155 secondary and above-level medical institutions in Sichuan Province that had implemented outpatient EMR were selected by stratified cluster random sampling method for a survey.A self-designed questionnaire was used.The survey content included basic information of medical institutions,outpatient EMR construction,application and management.Results Among the 155 medical institutions surveyed,107(69.03%)were tertiary-level institutions and 48(30.97%)were secondary-level institutions.Fully implemented and partially implemented outpatient EMR were reported in 142(91.61%)and 13(8.39%)institutions,respectively.The majority of institutions,95(61.29%),used semi-structured EMR templates.The ability to directly reference laboratory tests,ultrasonography,medical imaging,pathology reports,and outpatient medical history were reported in 141(90.97%),133(85.81%),127(81.94%),61(39.35%),and 92(59.35%)institutions,respectively.Moreover,151(97.42%)institutions utilized standardized diagnosis databases/health insurance diagnosis.Training related to medical record documentation was conducted by 144(92.90%)institutions for newly assigned outpatient doctors.And 149(96.13%)institutions had dedicated technical staff for system maintenance.In addition,53(34.19%)institutions allocated dedicated or part-time physician assistants to experts.And 11(7.10%)institutions provided auxiliary facilities such as voice input and image extraction in outpatient clinics.Conclusion There are differences in the level of outpatient EMR construction and management among medical institutions at different levels,and the level of EMR informatization in outpatient settings is inconsistent.Therefore,medical institutions should further enhance the construction and

关 键 词：医疗机构 门诊电子病历 现状 

分 类 号：R197.323[医药卫生—卫生事业管理]