推进电子病历信息化提高病历内涵质量的研究  

Research on Promoting the Informatization of Electronic Medical Records and Improving the Quality of Medical Record Content

作　　者：崔志伟 付翠平 林松 CUI Zhiwei;FU Cuiping;LIN Song(Department of Medical Quality Management,Liuzhou Workers'Hospital,Guangxi Zhuang Autonomous Region 545005,China;Department of Intensive Care Medicine,Liuzhou,Liuzhou Workers'Hospital,Guangxi Zhuang Autonomous Region 545005,China)

机构地区：[1]柳州市工人医院医疗质量管理科,广西柳州545005 [2]柳州市工人医院重症医学科,广西柳州545005

出　　处：《吉林医药学院学报》2024年第4期282-285,共4页Journal of Jilin Medical University

基　　金：广西壮族自治区卫生健康委自筹经费科研课题(Z-B20231381)。

摘　　要：目的以2022年国家病案管理质量控制中心发布的《提升病历内涵质量专项行动计划》文件为指导,探索提高病历内涵质量的管理方式。方法:以三级甲等公立医院2022—2023年度病历为研究对象。随机抽取2022年度手术病历、肿瘤化疗/放疗病历和输血病历各500份,共2000份为实验组;2023年度手术病历、肿瘤化疗/放疗病历和输血病历各500份,共2000份为对照组。实验组通过优化医疗数据利用、创新与扩展结构化电子病历模板、深化病历内涵质量系统信息化以及强化院级病历质量反馈工具信息化等质量监管方法,对照组采用传统方法。结果与对照组相比,实验组手术病历组出院记录24 h内完成率、CT/MRI检查记录符合率、病理检查记录符合率、抗菌药物使用记录符合率、手术相关记录完整率、医师查房记录完整率和知情同意书规范签署率明显提高,不合理复制病历发生率明显降低;肿瘤化疗病历组入院记录24 h内完成率、出院记录24 h内完成率、CT/MRI检查记录符合率、抗菌药物使用记录符合率、医师查房记录完整率和知情同意书规范签署率明显提高;肿瘤放疗病历组出院记录24 h内完成率、CT/MRI检查记录符合率、恶性肿瘤放射治疗记录符合率、医师查房记录完整率和知情同意书规范签署率明显提高,不合理复制病历发生率明显降低;输血病历组CT/MRI检查记录符合率、抗菌药物使用记录符合率、临床用血相关记录符合率、医师查房记录完整率和知情同意书规范签署率明显提高,差异具有统计学意义(P<0.05)。结论推进电子病历信息化可有效提升病历内涵质量。Objective Guided by the“Special Action Plan for Improving the Connotation Quality of Medical Records”released by the National Medical Record Management Quality Control Center in 2022,to explore management methods for improving the connotation quality of medical records.Methods The medical records of tertiary public hospitals from 2022 to 2023 were selected as the research object.500 surgical medical records,500 tumor chemotherapy/radiotherapy medical records,and 500 blood transfusion medical records were randomly selected for the year 2022,with a total of 2000 in the experimental group;In 2023,there were 500 surgical medical records,500 tumor chemotherapy/radiotherapy medical records,and 500 blood transfusion medical records,with a total of 2000 in the control group.The experimental group used quality supervision methods such as optimizing the utilization of medical data,innovating and expanding structured electronic medical record templates,deepening the informatization of medical record quality systems,and strengthening the informatization of hospital level medical record quality feedback tools.The control group used traditional methods.Results Compared with the control group,the experimental group showed a significant increase in the completion rate of discharge records within 24 hours,CT/MRI examination records,pathological examination records,antibacterial drug use records,surgical related records,physician rounds,unreasonable duplication of medical records,and standardized signing rate of informed consent forms in the surgical medical record group.The completion rate of admission records within 24 hours,completion rate of discharge records within 24 hours,CT/MRI examination records,antibacterial drug use records,physician rounds,and standardized signing rate of informed consent forms in the tumor chemotherapy medical record group were also significantly improved.The completion rate of discharge records within 24 hours and CT/MRI examination records in the tumor radiotherapy medical record group were als

关 键 词：电子病历信息化 病历内涵质量 病历质量同质化管理 

分 类 号：R197[医药卫生—卫生事业管理]