摘要
目的通过实地调研,对广东省公立医院电子病历建设情况和病案质量进行横断面调查,并评估电子病历系统建设对病案质量的影响。方法由来自广东省卫生健康委事务中心和广东省18家三甲医院的37位病案质控、病案管理及医院信息专家组成10个小组,对广东省20个地级市60家医院的电子病历水平和住院病案质量进行调研。根据电子病历评级和病案质控信息化情况,对住院病案进行分组,比较组间病案质量。结果本次调研抽检了23家三级医院住院病案共239份,甲级率为97.49%;抽检了37家二级医院住院病案共390份,甲级率为97.18%。23家三级医院电子病历系统评级均为3级及以上,37家二级医院中尚无电子病历系统评级为5级的医院。69.6%的三级医院采用了人工结合信息系统质控,仅27.0%的二级医院中采用人工结合信息系统质控。分析显示,不同电子病历系统评级组病案质量得分无统计学差异(H=1.113,P>0.05),而人工结合信息系统组病案质量得分高于仅人工质控组(Z=-2.894,P<0.01)。结论病案质控信息化能有效提高病案质量,医院应将其作为电子病历系统建设的重要内容。
Objective To make a cross-sectional survey of the construction of electronic medical records and the quality of medical records in public hospitals in Guangdong Province with field research,and to evaluate the influence of the construction of electronic medical record system on the quality of medical records.Methods Thirty-seven experts in the fields of medical record quality control,medical record management and hospital information from the Guangdong Provincial Health Commission Affair Center and 18 tertiary hospitals in Guangdong Province formed 10 groups to assess the levels of electronic medical record system and the quality of inpatient medical records of 60 hospitals in 20 prefecture-level cities in Guangdong Province.Medical records were divided into groups according to the electronic medical record rating and the informatization status of quality control,and the quality of medical records between groups were compared.Results Two hundred and thirty-nine medical records from 23 tertiary hospitals were sampled in this survey,with a grade A rate of 97.49%;390 inpatient medical records from 37 secondary hospitals were sampled,with a grade A rate of 97.18%.The electronic medical record system of 23 tertiary hospitals were rated at level 3 and above,and there was no hospital with electronic medical record system rating of level 5 among 37 secondary hospitals.Manual integrated information system quality control was adopted in 69.6%of the tertiary hospitals,and in 27.0%of the secondary hospitals.The analysis showed that there was no statistical difference in the medical record quality scores of different electronic medical record system rating groups(H=1.113,P>0.05),while the medical record quality score of the manual combined information system group was higher than that of the manual quality control group(Z=-2.894,P<0.01).Conclusion The informatization of medical record quality control can effectively improve the quality of medical records,and it is necessary for hospitals to take it as an important part of the construction of electronic medical record system.
作者
卢建军
辛子艺
余俊蓉
熊莺
Lu Jianjun;Xin Ziyi;Yu Junrong;Xiong Ying(Department of Medical Record Management,First Affiliated Hospital of Sun Yat-sen Univeristy,Guangzhou 510080,China;Information Data Center,First Affiliated Hospital of Sun Yat-sen Univeristy,Guangzhou 510080,China)
出处
《中国医院统计》
2022年第3期228-231,共4页
Chinese Journal of Hospital Statistics
基金
广东省卫生经济学会面上课题(2021-WJMZ-16)。
关键词
电子病历评级
信息化
病案质量
公立医院
绩效考核
electronic medical record rating
informatization
medical record quality
public hospital
performance appraisal
作者简介
第一作者:卢建军,Email:309327105@qq.com;通信作者:熊莺,Email:1907264574@qq.com。
