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目的比较观察电子病历对病案质量的影响。方法病案委员会发现差错,由医务处确定处理的病历共514份,其中完全手写病历244份,电子打印病历270份。差错分为纯粹电子病历引起的、责任心不足和能力不足三部分,比较两组差错的构成。结果与手工病历相比,电子打印病历差错发生率1.99个/份,较手写病历2.78个/份明显减少;电子打印病历差错中完全由电子病历因素引起的差错占5.96%;责任心不足引起的占44.88%,较手工病历的55.38%有所下降。但能力不足所引起的差错由44.62%增加到49.16%。结论使用电子病历,可以提高病案质量,但更需要提高病历书写能力。
Objective To compare the effects of electronic medical records on medical record quality. Methods The case record found errors, the medical department determined to deal with a total of 514 medical records, of which 244 were handwritten medical records, electronic print medical records 270. Errors are divided into purely electronic medical records caused, lack of responsibility and lack of capacity in three parts, the composition of the two sets of errors. Results Compared with manual medical record, the incidence rate of electronic print medical record error was 1.99 per copy, which was significantly lower than that of handwritten medical record 2.78 per copy. The error caused by electronic medical record was accounted for 5.96% Accounting for 44.88%, 55.38% lower than manual medical records. However, the number of errors caused by insufficient capacity increased from 44.62% to 49.16%. Conclusion The use of electronic medical records can improve the quality of medical records, but more need to improve the medical record writing ability.