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目的探讨环节质控及质控结果的奖罚对电子病历质量影响的效果分析。方法以2012年10月-2012年12月、2013年1月-2013年3月及2013年4月-2013年6月三个阶段各随机抽取的1000份电子运行病历为研究对象,计算三个阶段病历的时限性缺陷、书写性缺陷及甲级率,结果使用SPSS11.0软件统计,率的比较采用χ2检验。结果 2013年1月-2013年3月与2012年10月-2012年12月比较,电子运行病历的时限性缺陷与书写性缺陷均下降(P<0.01),病案甲级率升高11.1%,乙级率下降15%(P<0.01),无丙级病历;2013年4月对电子病历缺陷实行奖惩后,电子运行病历时限性缺陷与书写性缺陷均下降(P<0.05),病案甲级率升高7.6%,乙级率下降2.6%(P<0.05)。结论环节质控是提高电子病历质量的重要方法,而奖惩措施是很好的助力。
Objective To explore the effect of rewards and punishments of quality control and quality control on the quality of electronic medical records. Methods A total of 1000 electronic operating medical records were randomly selected from October 2012 to December 2012, January 2013 to March 2013 and April 2013 to June 2013 respectively. Three Time-limited medical records of stage defects, writing defects and grade A, the results using SPSS11.0 software statistics, the rate of comparison using χ2 test. Results Compared with the data from January 2012 to March 2013 and October 2012 to December 2012, the time-limited and written defects of electronic medical records were both decreased (P <0.01). The case-rate increased by 11.1% Grade B dropped by 15% (P <0.01) and no Grade C medical records. After rewards and punishments of electronic medical records in April 2013, the time-limited and written defects of electronic medical records decreased (P <0.05) Rates rose 7.6%, while rates of B dropped 2.6% (P <0.05). Conclusion Quality control is an important way to improve the quality of electronic medical records, and reward and punishment measures are very helpful.