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目的对网络实时监控电子运行病历的效果进行评价。方法以卫生部《病历书写基本规范》为标准,对某大型三甲综合医院实施网络实时监控前后的电子运行病历质量进行统计分析。结果电子运行病历在一定程度上存在不同缺陷,实施网络实时监控后,电子运行病历的质量有明显改变,其中病历合格率、72小时三级医师查房记录缺失发生率、入院记录缺失发生率的改变等共10项差异有统计学意义(P<0.005)。结论网络实时监控提高了电子运行病历的合格率,减少了电子运行病历中存在的各类缺陷。
Objective To evaluate the effect of network real-time monitoring of electronic medical record. Methods Based on the “Basic Norms of Medical Records Writing” issued by the Ministry of Public Health, a statistical analysis was made on the quality of electronic medical records before and after the implementation of network real-time monitoring in a large general hospital. Results The electronic medical record had some defects. After the network real-time monitoring, the quality of electronic medical records changed significantly. The qualified rate of the medical records, the incidence of the third-round physician check-in records at 72 hours and the incidence of the missing records of the admission records Change a total of 10 differences were statistically significant (P <0.005). Conclusion The network real-time monitoring improves the qualified rate of electronic operation medical records and reduces various defects existing in electronic operation medical records.