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目的探讨电子病历系统书写入院记录的效率。方法将16位学历、实习时间相同的实习医生随机分成2组,分别使用电子病历系统方法与传统的手工方法书写入院记录;1周后,2组人员调换,再次书写相同入院记录,全过程实时记录完成入院记录各部分的时间。将医生完成入院记录的时间换算为速度分数,专家对病历的评分记为质量分数,二者加权后得到综合分数,并对两种方法进行统计检验。结果在完成时间上,电子病历系统方法组书写入院记录平均总用时为19．85min,手写方法组为39．49min;在完成质量上,现病史、既往史、个人史、家族史和体格检查5项及总体得分电子病历系统方法组高于手写方法组;在综合效率上,电子病历系统方法组平均分数为91．13分,手工方法组为65．72 分,其差异具有统计学意义(P<0．01)。结论电子病历系统方法能够有效提高入院记录书写速度和质量,大大减轻医生书写入院记录的工作量,书写入院记录效率明显优于手工方法。
Objective To explore the efficiency of electronic medical record system in writing admission records. Methods 16 trainees with the same academic qualifications and the same internship time were randomly divided into two groups. The records were recorded using the electronic medical record system and the traditional manual method respectively. After 1 week, the two groups of trainees were replaced and the same admission records were written again. The whole process was real-time Record the time to complete each part of admission record. The doctors completed the admission record time is converted to speed score, the medical record of the score recorded as the quality score, the two weighted comprehensive score, and the two methods of statistical testing. Results At the time of completion, the average time spent on electronic medical record system was 19.85 minutes and that of handwritten method was 39.49 minutes. In terms of quality of completion, current medical history, past medical history, personal history, family history and physical examination 5 Items and overall score of electronic medical records system method group than the handwriting method group; in the overall efficiency, the electronic medical record system method group average score of 91.13 points, manual method group was 65.72 points, the difference was statistically significant (P <0.01). Conclusion The electronic medical records system can effectively improve the writing speed and quality of admission records and greatly reduce the workload of doctors writing admission records. The efficiency of writing admission records is obviously better than manual methods.