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目的:探讨电子病历模式下如何提高病案的内涵质量。方法:检查2014年1~10月全部在院病案,采用电子初检和人工抽检相结合的方式,取得相应的综合得分,并对所有扣分项目进行数据分析。结果:电子初检病历共19916份,合格率46.01%。人工抽检病历共3268份,合格率为44.69%。电子初检扣分项目排前3位为上级医师查房433.1分、病程记录252.2分、首次病程记录238.5分。人工抽检扣分项目排前3位的为病程记录243.9分、入院记录60.4分、中医辨病辨证56.1分。结论:电子初检可提高病案书写的及时性和规范性,使病案质量得到全面提高。
Objective: To explore how to improve the connotation quality of medical records under the electronic medical record mode. Methods: All hospitalized cases from January to October of 2014 were examined. The combination of primary electronic examination and manual sampling was used to obtain the corresponding comprehensive score and all the deducted items were analyzed. Results: There were 19,916 medical electronic medical examinations with a pass rate of 46.01%. A total of 3268 manual sampling medical records, a pass rate of 44.69%. The first three electronic deduction items ranked 433.1 points for physicians ward rounds, 252.2 points record of the disease, the first recorded 238.5 points course of disease. The top three of the items in the manual examination were 243.9 points of course of disease, 60.4 points of admission records and 56.1 points of syndrome differentiation of traditional Chinese medicine. Conclusion: The first electronic examination can improve the timeliness and standardization of medical record writing, so that the medical record quality can be fully improved.