数字化病案信息技术在医院工作中的应用  

The Use of Digital Case Information Technology in Hospital Work

作　　者：翟文献 王梅 ZHAI Wenxian;WANG Mei(Medical Record Management Department of Zibo Hospital of Traditional Chinese Medicine,Zibo 255300,Shandong,China)

机构地区：[1]淄博市中医医院病案管理科,山东淄博255300

出　　处：《中国卫生产业》2024年第12期138-141,共4页China Health Industry

摘　　要：目的探讨数字化病案信息技术在医院工作中的应用。方法选取2018年5月—2019年5月淄博市中医院病案管理科10名工作人员和400份病案作为对照组,2019年6月—2020年6月10名工作人员和400份病案作为观察组,两组为同一批工作人员。对照组采用常规管理,观察组采用数字化病案信息技术。对比两组的工作质量、管理情况、调用时间以及保存满意度。结果观察组书写错误、书写不规范、病案归档返修率均低于对照组,差异有统计学意义(P均<0.05);观察组病案管理中首页合格率、ICD编码、归档正确率、3日回收率情况均高于对照组,差异有统计学意义(P均<0.05);观察组病案平均调用时间比对照组时间更短,差异有统计学意义(P<0.05);观察组对病案保存满意度评分为(95.16±2.65)分,高于对照组的(86.78±2.62)分,差异有统计学意义(t=7.111,P<0.05)。结论数字化病案在医院工作的开展,使得工作质量和病案利用率得到提升,也加强了病案管理水平和保存满意度,减少了病案调用时间,具有临床运用价值。Objective To explore the application of digital medical record information technology in hospital work.Methods Ten staff members and 400 medical records of the Medical records Management Department of Zibo Hospital of Traditional Chinese Medicine from May 2018 to May 2019 were selected as the control group,and ten staff members and 400 medical records from June 2019 to June 2020 were selected as the observation group.The two groups were the same group of staff members.The control group adopted the routine management,and the observation group adopted the digital medical record information technology.The work quality,management,call time and retention satisfaction of the two groups were compared.Results The rates of writing errors,non-standard writing and archiving of medical records in the observation group were lower than those in the control group,and the differences were statistically significant(all P<0.05).The qualified rate of the first page,ICD code,filing accuracy and 3 days recovery rate in the observation group were higher than those in the control group,and the differences were statistically significant(all P<0.05).The average call time of medical records in the observation group was shorter than that in the control group,and the difference was statistically significant(P<0.05).The satisfaction score of the observation group was 95.16±2.65,higher than 86.78±2.62 of the control group,and the difference was statistically significant(t=7.111,P<0.05).Conclusion The development of digital medical records in the hospitals has improved the quality of work and the utilization rate of medical records.It has also strengthened the level of medical record management and preservation satisfaction,reduce the time of medical records call,has clinical application value.

关 键 词：数字化病案信息技术 ICD编码 病案首页 信息化建设 

分 类 号：R197[医药卫生—卫生事业管理]