摘要
目的对病历书写时限质量控制,提高病历质量。方法利用电子病历质量控制系统,对2019年3月份入院病历3483份、5月份入院病历3586份以及6月份入院病历3150份的入院记录、首次病程记录和主治医师首次查房记录的书写时限进行监控和检查。结果经过3个月监控检查、反馈、培训、落实奖惩措施,病历书写及时率持续改进。3月份、5月份、6月份入院记录的按时完成率分别是94.52%、97.49%、98.06%;首次病程记录的按时完成率分别是93.28%、96.6%、98.38%;主治医师首次查房记录的按时完成率分别是94.29%、97.3%、98.7%。结论利用电子病历质控系统,实时监控病历书写及时性,及时反馈,结合相关管理规定,能有效提高病历书写的及时性。
Objectives To strengthen the quality control of the writing time of medical records and improve the quality of medical records.Methods The electronic medical record quality control system was used to monitor and check the writing time of 3,483 medical records admitted in March 2019,3,586 medical records admitted in May and 3,150 medical records admitted in June.Results After 3 months of monitoring,feedback,training,implementation of reward and punishment measures,the timely writing rate of medical records continued to improve.The on-time completion rates of admission records in March,May and June were 94.52%,97.49%and 98.06%,respectively.The on-time completion rate of the first course record was 93.28%,96.60%and 98.38%,respectively.The on-time completion rate of the first ward rounds recorded by the attending physician was 94.29%,97.30%and 98.70%,respectively.Conclusions The use of electronic medical record quality control system,constantly monitoring the timeliness of medical record writing,timely feedback,combined with relevant management provisions,could effectively improve the timeliness of medical record writing.
作者
吴文健
孙晖
季国忠
WuWenjian;Sun Hui;Ji Guozhong(不详;The Medical and Politic College,Nanjing Medical University,Nanjing 211166,Jiangsu Province,China)
出处
《中国病案》
2020年第1期9-11,共3页
Chinese Medical Record
基金
江苏省卫生和计划生育委员会科研课题(G2017010).
关键词
电子病历
质量控制系统
病历书写
时限
Electronic medical record
Quality control system
Writing medical records
Time limit
