摘要
目的研究电子病历实时监控系统在结核病病案管理中的应用效果。方法将2021年1月-2022年12月横峰县疾控中心采用电子病历实时监控系统对结核病病案进行管理的60例结核病患者设为观察组,2019年1月-2020年12月未采用电子病历实时监控系统对结核病病案进行管理的60例结核病患者设为对照组。比较两组病案差错率、病案质量水平、病案管理效率、各类人员满意度。结果观察组病程记录不全、出院记录、病案首页录入差错率均低于对照组(P<0.05);观察组病案书写、病程记录、住院记录、病案首页、辅助检查、出院记录评分均高于对照组(P<0.05);观察组病案整理时间、病案查阅时间均短于对照组(P<0.05);观察组医生、护理人员、病案管理人员满意度均高于对照组(P<0.05)。结论电子病历实时监控系统在结核病病案管理中具有重要的作用,可促进结核病病案管理,提高病案管理效率,减少病案差错率,提升各类人员满意度。
Objective To study the application effect of electronic medical record real-time monitoring system in tuberculosis medical record management.Methods From January 2021 to December 2022,60 tuberculosis patients who were managed by the Hengfeng County Center for Disease Control using the electronic medical record real-time monitoring system were set as the observation group,and from January 2019 to December 2020,60 tuberculosis patients who were not managed by the electronic medical record real-time monitoring system were set as the control group.The medical record error rate,medical record quality level,medical record management efficiency,and satisfaction of various personnel were compared between the two groups.Results The error rates of incomplete course records,discharge records and front page entry of medical records in the observation group were lower than those in the control group(P<0.05).The scores of medical record writing,course record,hospitalization record,home page of medical record,auxiliary examination and discharge record in the observation group were higher than those in the control group(P<0.05).The time of medical record arrangement and medical record review in the observation group were shorter than those in the control group(P<0.05).The satisfaction of doctors,nurses and medical record managers in the observation group was higher than that in the control group(P<0.05).Conclusion The electronic medical record real-time monitoring system has important application effect in the management of tuberculosis medical records,which can promote the management of tuberculosis medical records,improve the efficiency of medical records management,reduce the error rate of medical records,and improve the satisfaction of hospital staff with different occupations。
作者
张思危
ZHANG Si-wei(Department of Tuberculosis Control,Hengfeng County Center for Disease Control,Hengfeng 334300,Jiangxi,China)
出处
《医学信息》
2023年第22期41-44,共4页
Journal of Medical Information
关键词
电子病历
实时监控系统
结核病
病案管理
Electronic medical record
Real-time monitoring system
Tuberculosis
Medical record management
