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目的加强按时完成病历纪录的管理,提高病案质量。方法利用电子病历系统,对2012年1月至2012年3月所有病房科室的入院记录和首次病程记录的书写时限进行监控。并实施改进措施,如及时向临床科室反馈,加强科室管理,进行培训并与奖惩挂钩等。结果 1季度首次病程记录的按时完成率85.19%,入院记录按时完成率89.51%,首次病程记录超时在48小时之内占70.19%,入院记录超时在48小时之内占53.39%。实施改进措施后,3月份首次病程记录按时完成率97.25%,入院记录按时完成率96.56%,1月份与3月份比较,P值<0.01,明显改善。结论利用电子病历系统可以有效的监控病案完成时间,从而加强对病案的管理,改善病案质量。
Objective To strengthen the management of record records on time and improve the quality of medical records. Methods The electronic medical record system was used to monitor the writing time of admission records and first course records of all ward departments from January 2012 to March 2012. And implement improvement measures, such as timely feedback to clinical departments, strengthen department management, training and rewards and punishments linked to. Results The rate of completion of the first course record was 85.19% in 1Q. The completion rate of admission was 89.51% on time. The first course record timeout was 70.19% within 48 hours and the admission record timeout was 53.39% within 48 hours. After implementing the improvement measures, the first time course record of March was 97.25% of the time, the completion rate of admission was 96.56% on time. Compared with March, the P value was less than 0.01 in January and significantly improved. Conclusion The use of electronic medical records system can effectively monitor the completion of medical records, so as to strengthen the management of medical records and improve the quality of medical records.