摘要
目的:实行网上环节质量控制前后,对573例电子病案首页填写缺陷比较分析。方法:抽查医院2017年10-12月至2018年1-3月份电子病历首页573份,首先对未经网上质控和经过24小时内网上环节质控两个阶段的病案首页填写不合格率及缺陷情况进行比较分析,其次对两阶段的病案首页缺陷8项占比对比。结果:2017年10-12月电子病案首页填写不合格率为32.2%,缺陷率66.7%;2018年1-3月份电子病案首页填写不合格率为8.5%,缺陷率37.8%;缺陷率下降43.3%。经两阶段比较,2018年1-3月份的电子病案首页缺陷8项占比均大幅下降,数据采用统计学软件Spss18.0进行分析,χ2值分别为32.69,15.29,以P<0.01为差异有统计学意义。结论:医院24小时内实行网上环节质控电子病历首页,病历首页缺陷大幅下降,病案质量大幅提高,效果显著。
Objective:To compare and analyze 573 cases of electronic medical record homepage filling defects before and after the implementation of online quality control.Method:to randomly check the first pages of electronic medical records in hospitals from October to December 2017 to January to March 2018.Firstly,a comparative analysis of the unqualified rate and defect situation on the homepage of the medical record without online quality control and the online quality control within 24 hours is made,and then the proportions of 8 defects on the first page of the medical records of the two stages are compared.Results:From October to December 2017,the unqualified rate of filling in the first page of electronic medical records was 32.2%,and the defect rate was 66.7%;the unqualified rate of filling in the first page of electronic medical records from January to March 2018 was 8.5%,and the defect rate was 37.8%;the defect rate is decreased by 43.3%.After comparing the two phases,the proportion of 8 defects on the first page of electronic medical records from January to March 2018 has dropped significantly.The data is analyzed by using statistical software Spss18.0.Theχ2 value is 32.69 and 15.29 respectively,and the difference is statistically if P<0.01.Conclusion:The hospital implements online quality control of the electronic medical record homepage within 24 hours,the defects of the medical record homepage are greatly reduced,the quality of medical records is greatly improved,and the effect is significant.
作者
徐继红
曹莉莉
董兴军
XU Ji-hong;CAO Li-li;DONG Xing-jun(Qianjiang City Dermatology Prevention and Treatment Hospital,Qianjiang 433199,China)
出处
《价值工程》
2020年第25期185-186,共2页
Value Engineering
关键词
病案首页
网上环节质控
缺陷分析
medical record homepage
online link quality control
defect analysis
