电子运行病历质量控制分析

JOURNAL OF SHANDONG UNIVERSITY (HEALTH SCIENCES) ›› 2014, Vol. 52 ›› Issue (Z1): 212-213.

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Study on quality control in management of electronic medical records

LI Lan

Quality Control Center of Hyperbaric oxygen, Chengdu First People's Hospital, Chengdu 610041, China

Received:2014-11-30 Online:2014-12-30 Published:2014-12-30

Abstract

Abstract: Objective To discuss the quality control in managing electronic medical records. Methods A total of 664 electronic medical records were selected though online system as computer group. Another 250 electronic medical records of in-patients were selected manually as ward group. The defects in electronic medical records were summarized and compared between 2 groups. Results There was no significant difference in rate of class A record between two groups. Main defects found was insufficient of medical history (46.7%), insufficient of general data (18.3%) and insufficient of progress note (12.3%). Conclusion it is necessary to strengthen the supervision in quality control of electronic medical records.

Key words: Electronic medical records, Digitization, Supervision

CLC Number:

R197.32

LI Lan. Study on quality control in management of electronic medical records[J].JOURNAL OF SHANDONG UNIVERSITY (HEALTH SCIENCES), 2014, 52(Z1): 212-213.

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