电子病历对病案回收效率及病案首页数据质量的影响
|
摘要
目的探讨电子病历对病案回收效率及病案首页质量的影响,为电子病历的推广提供参考。方法回顾性分析广西某三甲医院实施电子病历前(2011年1月1日～12月31日)、后(2012年1月1日～12月31日)所有临床科室的病案回收数量、回收率、平均回收时间,从完整性、逻辑性、规范性3个维度对实施电子病历前后2个时段病案首页数据质量进行评估。结果实施电子病历后2、3、7个工作日回收率分别由23.78%提高到42.45%、由38.17%提高到56.55%、由86.12%提高到92.75%(P=0.000),平均回收时间由(4.50±1.50)d降低至(3.42±1.10)d,差异具有统计学意义(t=33.118,P=0.000)。应用电子病历后病案首页项目完整率、规范率和逻辑符合率明显优于应用电子病历前。结论电子病历明显提高病案回收率,提高病案首页质量,值得医院推广。
Objective To explore the influence of electronic medical records on the recovery efficiency of medical records and the quality of medical records, and to provide reference for the promotion of electronic medical records.Methods The recovery quantity, recovery rate, and average recovery time of medical records in a top three hospital in Guangxi before(from January 1 to December 31, 2011) and after the implementation of the electronic medical records(from January 1 to December 31, 2012) were retrospective analyzed. The data quality of the home page of the medical records during the two periods before and after the implementation of the electronic medical records were evaluated from the three dimensions of integrity, logic and normativeness. Results The recovery rate of 2, 3, and 7 working days after the implementation of electronic medical records increased from 23.78% to 42.45%, from 38.17% to 56.55%, from86.12% to 92.75%(P=0.000). And the average recovery time decreased from(4.50±1.40) days to(3.42±1.10) days, and the difference was statistically significant(t=33.118, P=0.000). After the application of the electronic medical record, the complete rate, standardization rate and logical compliance rate of the home page of the medical record were obviously superior to those before the application of the electronic medical record. Conclusion Electronic medical records can significantly improve the recovery rate of medical records and improve the quality of medical records. It is worthy of hospital promotion.
Objective To explore the influence of electronic medical records on the recovery efficiency of medical records and the quality of medical records, and to provide reference for the promotion of electronic medical records.Methods The recovery quantity, recovery rate, and average recovery time of medical records in a top three hospital in Guangxi before(from January 1 to December 31, 2011) and after the implementation of the electronic medical records(from January 1 to December 31, 2012) were retrospective analyzed. The data quality of the home page of the medical records during the two periods before and after the implementation of the electronic medical records were evaluated from the three dimensions of integrity, logic and normativeness. Results The recovery rate of 2, 3, and 7 working days after the implementation of electronic medical records increased from 23.78% to 42.45%, from 38.17% to 56.55%, from86.12% to 92.75%(P=0.000). And the average recovery time decreased from(4.50±1.40) days to(3.42±1.10) days, and the difference was statistically significant(t=33.118, P=0.000). After the application of the electronic medical record, the complete rate, standardization rate and logical compliance rate of the home page of the medical record were obviously superior to those before the application of the electronic medical record. Conclusion Electronic medical records can significantly improve the recovery rate of medical records and improve the quality of medical records. It is worthy of hospital promotion.
引文
[1]王玮.加强电子病案管理确保医疗安全[J].中国临床研究,2014,27(9):1158-1160.
[2]唐杰.重庆市沙坪坝电子病历系统的设计与实现[D].重庆大学,2014.
[3]赵旭冰.基于云存储的电子病历访问控制策略研究[D].北方工业大学,2017.
[4]杨霜英,周丽君,于京杰.基于缩微数码影像技术的数字化病案管理系统的研究[J].中国医学装备,2013,(9):15-17.
[5]梁伟业,辛立敏,白璐源,等.基于电子病历的医院病历档案管理实践[J].中国档案,2018,(8):42-43.
[6]孙立娟,高亚菊.护理文件书写质控检查中发现的问题及应对策略[J].齐齐哈尔医学院学报,2014,(24):3744.
[7]王理,张远鹏,董建成.利用领域关联知识从电子病历中抽取检查数据[J].中华医院管理杂志,2014,30(3):210-213.
[8]韩晨光,李玉明,韩慧娟,等.电子病历应用优势、注意问题与对策[J].中国医院,2007,11(5):42-44.
[9]钱文婷.电子病历在放射科护理工作中的应用[J].齐齐哈尔医学院学报,2013,34(8):1204-1206.
[10]吴骋,秦婴逸,肖翔,等.病案首页数据质量的量化评估方法研究及应用[J].中国病案,2016,17(3):10-13.
[11]李红梅.条形码技术在病案信息化管理中的应用[J].福建医药杂志,2015,37(4):174-175.
[12]赵芹,尤秀芝.根本原因分析法在出院病案归档管理中的应用[J].新疆医学,2015,45(8):1176-1177.
[13]高维亚.影响病案回收的原因及对策[J].中国病案,2006,7(8):8-9.
[14]曲虹,宋文燕.医院管理措施对病案回收的影响[J].中国病案,2016,17(2):6-8.
[15]杨立红.PDCA循环法对某医院病案回收管理的影响分析[J].解放军预防医学杂志,2016,34(4):535-537.
[16]刘泽文,陶燕.基于PDCA循环病案管理流程的优化和改进措施研究[J].当代医学,2017,23(12):54-56.
[17]迪里木拉提·买买提,古扎力阿衣·肉孜,阿布都沙拉木·依米提.住院病案回收率影响因素分析[J].中国病案,2017,18(4):5-7.
[18]任学婧,朱勇.电子病历的证据效力[J].华北理工大学学报(医学版),2009,11(3):417-418.
[19]解卫军.依据HQMS数据标准建立电子病历首页在线质量控制系统的设计与实现[J].医学信息,2016,29(28):1-2.
[20]杨伟东,高春兴.出院病案首页数据质量的分析方法与应用[J].中国病案,2017,18(2):19-22.
[21]陈娴,王占明,范艳妮,等.19300份电子病案首页填写质量分析[J].中国病案,2016,17(6):11-14.
[22]熊莺,卢建军.新形势下医院病案管理面临的问题与挑战[J].现代医院,2016,16(11):1691-1693.
[23]杨燕媚.电子病历系统对病案管理的促进作用[J].中国当代医药,2016,23(8):180-182.
[24]钟菊珍,袁虹,郭玉花,等.探讨新时期医院病案管理的方法与改进[J].中国医药科学,2016,6(11):189-192.
[25]郑桂华,周旭文,郑烈辉,等.电子病案对病案管理职能转变的作用探究[J].中国医药科学,2017,7(1):130-132.
[2]唐杰.重庆市沙坪坝电子病历系统的设计与实现[D].重庆大学,2014.
[3]赵旭冰.基于云存储的电子病历访问控制策略研究[D].北方工业大学,2017.
[4]杨霜英,周丽君,于京杰.基于缩微数码影像技术的数字化病案管理系统的研究[J].中国医学装备,2013,(9):15-17.
[5]梁伟业,辛立敏,白璐源,等.基于电子病历的医院病历档案管理实践[J].中国档案,2018,(8):42-43.
[6]孙立娟,高亚菊.护理文件书写质控检查中发现的问题及应对策略[J].齐齐哈尔医学院学报,2014,(24):3744.
[7]王理,张远鹏,董建成.利用领域关联知识从电子病历中抽取检查数据[J].中华医院管理杂志,2014,30(3):210-213.
[8]韩晨光,李玉明,韩慧娟,等.电子病历应用优势、注意问题与对策[J].中国医院,2007,11(5):42-44.
[9]钱文婷.电子病历在放射科护理工作中的应用[J].齐齐哈尔医学院学报,2013,34(8):1204-1206.
[10]吴骋,秦婴逸,肖翔,等.病案首页数据质量的量化评估方法研究及应用[J].中国病案,2016,17(3):10-13.
[11]李红梅.条形码技术在病案信息化管理中的应用[J].福建医药杂志,2015,37(4):174-175.
[12]赵芹,尤秀芝.根本原因分析法在出院病案归档管理中的应用[J].新疆医学,2015,45(8):1176-1177.
[13]高维亚.影响病案回收的原因及对策[J].中国病案,2006,7(8):8-9.
[14]曲虹,宋文燕.医院管理措施对病案回收的影响[J].中国病案,2016,17(2):6-8.
[15]杨立红.PDCA循环法对某医院病案回收管理的影响分析[J].解放军预防医学杂志,2016,34(4):535-537.
[16]刘泽文,陶燕.基于PDCA循环病案管理流程的优化和改进措施研究[J].当代医学,2017,23(12):54-56.
[17]迪里木拉提·买买提,古扎力阿衣·肉孜,阿布都沙拉木·依米提.住院病案回收率影响因素分析[J].中国病案,2017,18(4):5-7.
[18]任学婧,朱勇.电子病历的证据效力[J].华北理工大学学报(医学版),2009,11(3):417-418.
[19]解卫军.依据HQMS数据标准建立电子病历首页在线质量控制系统的设计与实现[J].医学信息,2016,29(28):1-2.
[20]杨伟东,高春兴.出院病案首页数据质量的分析方法与应用[J].中国病案,2017,18(2):19-22.
[21]陈娴,王占明,范艳妮,等.19300份电子病案首页填写质量分析[J].中国病案,2016,17(6):11-14.
[22]熊莺,卢建军.新形势下医院病案管理面临的问题与挑战[J].现代医院,2016,16(11):1691-1693.
[23]杨燕媚.电子病历系统对病案管理的促进作用[J].中国当代医药,2016,23(8):180-182.
[24]钟菊珍,袁虹,郭玉花,等.探讨新时期医院病案管理的方法与改进[J].中国医药科学,2016,6(11):189-192.
[25]郑桂华,周旭文,郑烈辉,等.电子病案对病案管理职能转变的作用探究[J].中国医药科学,2017,7(1):130-132.