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目的了解电子病案系统在临床应用后对病历书写的快捷性、方便性和病案的安全性及内涵质量的影响。方法采用现场观察和问卷调查的方法对临床医师进行电子病案实施前后对比调查,并采用病案个案评价方法对电子归档病案进行内涵质量评价。结果实施电子病案系统后,入院记录和首次病程记录书写时间分别平均缩短了16.1分钟和11.9分钟;编辑、审查病案和书写医嘱较实施前更方便(P<0.01),然而电子病案查房、签名等方面不方便;容易出现病历未及时签名、被篡改、拷贝,医嘱开错等安全隐患。结论电子病案系统在临床应用中更快捷、更方便,容易出现一些质量问题和安全隐患,因此当前有必要研发出新的质量监测体系,促成电子病案对医疗质量的提高作用。
Objective To understand the effect of the electronic medical record system on the medical record writing convenience, convenience and medical record safety and connotation quality after clinical application. Methods Using on-the-spot observation and questionnaire survey, clinicians conducted a comparative survey before and after the implementation of the electronic medical records, and evaluated the quality of electronic filing medical records using the case evaluation method. Results After the implementation of the electronic medical record system, the admission records and the writing time of the first course record were shortened by an average of 16.1 minutes and 11.9 minutes respectively. Editing, reviewing medical records and writing medical orders were more convenient than before (P <0.01) And other aspects inconvenient; prone to medical records did not sign in time, was tampered with, copy, doctor’s advice wrong and other security risks. Conclusion The electronic medical record system is faster and more convenient in clinical application and prone to some quality problems and potential safety issues. Therefore, it is necessary to develop a new quality monitoring system to promote the improvement of medical record quality.