住院病案无纸化的改进与优化:以重症医学科为例  

Improvement and optimization of paperless inpatient medical records:a case study of intensive care medicine

作　　者：魏丹丹 刘晓东 WEI Dandan;LIU Xiaodong(Department of Critical Care Medicine,Xiangyang Central Hospital,Affiliated Hospital of Hubei University of Arts and Sciences,Xiangyang 441021,Hubei Province,China;Information Center,Xiangyang Central Hospital,Affiliated Hospital of Hubei University of Arts and Sciences,Xiangyang 441021,Hubei Province,China)

机构地区：[1]湖北文理学院附属襄阳市中心医院急症重症医学科,湖北襄阳441021 [2]湖北文理学院附属襄阳市中心医院信息中心,湖北襄阳441021

出　　处：《中国数字医学》2025年第3期66-71,共6页China Digital Medicine

摘　　要：目的:提高案例医院住院病案无纸化建设水平,缩短病案提交周期,减少护理病案质控时间和降低病案打回率。方法:以重症医学科提交的无纸化病案为研究对象,分析无纸化系统建设情况,对电子病历系统、手术麻醉系统和检查报告系统完成改造和优化,提高案例医院无纸化率。结果:优化后重症医学科无纸化率由(90.10±1.23)%增长至(95.60±1.41)%,全院无纸化率由(89.02±2.03)%增长至(92.58±2.81)%,差异均有统计学意义(P <0.05)。结论:通过对电子病历系统、手术麻醉系统和检查报告系统改造,提升了无纸化率,减少了护理质控病案时间,降低了病案打回率,提高了医院无纸化建设水平。Objective To enhance the level of paperless medical records application in case hospitals,shorten the submission cycle of medical records,reduce the quality control time of nursing medical records,and lower the rejection rate of medical records.Methods Taking the paperless medical records submitted by the Department of Intensive Care Medicine as the research object,the construction of paperless system was analyzed,and the electronic medical record system,surgical anesthesia system and examination report system were reformed and optimized to improve the paperless rate of case hospitals.Results After optimization,the paperless rate of Intensive Care Medicine Department increased from(90.10±1.23)%to(95.60±1.41)%,and the paperless rate of the whole hospital increased from(89.02±2.03)%to(92.58±2.81)%,and the differences were statistically significant(P<0.05).Conclusion Through the reformation of electronic medical record system,operation anesthesia system and examination report system,the paperless rate was inproved,the time of nursing quality control records was reduced,and the return rate of medical records decreased,the level of paperless application in the hospital can be improved.

关 键 词：无纸化 电子病历 患者签名 护理病案质控 

分 类 号：R197.3[医药卫生—卫生事业管理] R319[医药卫生—公共卫生与预防医学]