摘要
目的比较观察电子病历对病案质量的影响。方法病案委员会发现差错,由医务处确定处理的病历共514份,其中完全手写病历244份,电子打印病历270份。差错分为纯粹电子病历引起的、责任心不足和能力不足三部分,比较两组差错的构成。结果与手工病历相比,电子打印病历差错发生率1.99个/份,较手写病历2.78个/份明显减少;电子打印病历差错中完全由电子病历因素引起的差错占5.96%;责任心不足引起的占44.88%,较手工病历的55.38%有所下降。但能力不足所引起的差错由44.62%增加到49.16%。结论使用电子病历,可以提高病案质量,但更需要提高病历书写能力。
Objective To observe the effect of electronic printed medical records on medical record quality.Methods There were 514 medical records which were found mistakes by medical record committee and were disposed by medical department.There were 244 handwritten medical records,and 270 electronic medical record.Mistakes due to electronic medical records,lack of responsibility or lack of capacity.Comparing these two groups of mistakes.Results Comparing to 2.78 a/copy of the handwritten medical records,the error rate of electronic medical records is 1.99 a/copy.Mistakes due to electronic medical records is 5.96%,lack of responsibility is 44.88% and lack of capacity improved from 44.62% to 49.16%.Conclusion Using electronic medical records can improve the medical record quality,however,medical records writing capacity needs to be emphasized to improve.
出处
《中国病案》
2011年第6期40-41,共2页
Chinese Medical Record
关键词
电子病历
病案质量
Electronic medical record（EMR）
Medical record quality
