电子运行病历质量控制分析

山东大学学报（医学版） ›› 2014, Vol. 52 ›› Issue (Z1): 212-213.

电子运行病历质量控制分析

李兰

成都市第一人民医院高压氧质控中心, 四川成都 610041

收稿日期:2014-11-30 出版日期:2014-12-30 发布日期:2014-12-30

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

摘要/Abstract

摘要： 目的探讨电子运行病历的质量管理。方法计算机在线随机抽取电子病历664份为计算机组,同时抽取住院病房电子病历250份为病房组,对比2组电子运行病历质量,并总结计算机组电子运行病历缺陷。结果 2组电子运行病历甲级率差异无统计学意义 (P>0.05);电子运行病历缺陷中,入院记录现病史不全46.7%,一般情况缺陷18.3%,日常病程记录缺陷12.3%。结论应加强电子病历实时监控,提高质量控制工作效率。

关键词: 数字化, 实施监控, 运行病历

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

中图分类号:

R197.32

李兰. 电子运行病历质量控制分析[J]. 山东大学学报（医学版）, 2014, 52(Z1): 212-213.

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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