摘要
目的通过实时监控,提高运行电子病历书写质量。方法应用电子病历系统随机抽取3963份运行病历进行实时监控,对发现缺陷进行统计分析。结果在入院记录中基本信息填写缺陷频率占37.4%,其次为时限性问题和复制粘贴错误等。通过实时监控,运行病历缺陷率不断降低,分别为18.92%、17.68%和15.55%。结论电子病历实时质控是提高病历质控工作效率、促进病案质量提升的高效方法。
Objective This article improves the quality of running electronic medical record by real time monitoring.Methods 3963 running medical records are selected randomly through using EMR system had statistical analysis on the problem during monitoring.Results In 3963 medical records,the defect rate of basic information of admission record ranks first,which accounts for 37.4% of all defects,time limit and paste and copy come next.Through real time monitoring,the defect rates of medical record were reduced month by month from September to November,which defect rates were respectively 18.92%,17.68%,15.55%.Conclusions Real time quality monitor of EMR is a high efficiency method to improve work efficiency of quality control of medical records and improve medical records quality.
出处
《中国病案》
2012年第5期23-24,共2页
Chinese Medical Record
关键词
电子病历
实时监控
缺陷分析
EMR
Real time monitoring
Defects analysis
