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目的探讨电子病历环节质控对病案质量的影响。方法随机抽取2012年7月到2012年12月终末病案6200份和2013年1月至2013年6月通过网络环节质控电子运行病历6200份,并追踪经环节质控后的终末病历质量。按照卫生部制定的《病历书写基本规范》对终末病案进行检查评估,针对病案质量、实时性缺陷、书写缺陷等数据进行统计分析。结果 2013年1月-6月较2012年7月-12月病案甲级率升高4.46%(P<0.01),乙级率下降4.43%(P<0.01),丙级率由0.03%降为0%;实时性缺陷率明显下降,书写缺陷较前下降。结论电子病历环节质控减少病历缺陷的发生,有效提高终末病案质量。
Objective To explore the impact of electronic medical record quality control on medical record quality. Methods A total of 6200 medical records from July 2012 to December 2012 and 6,200 electronic medical records through network were collected randomly from January 2012 to June 2013. The quality of the final medical records after the quality control was tracked . In accordance with the “basic norms of medical record writing” formulated by the Ministry of Health, the final medical record was evaluated and evaluated. Data were analyzed for the quality of medical records, real-time defects and writing defects. Results The grade A rate of cases in January-June 2013 was 4.46% (P <0.01) higher than that of July-December 2012, the rate of class B was decreased by 4.43% (P <0.01), and the rate of class C was reduced from 0.03% 0%; real-time defect rate decreased significantly, write defects decreased compared with the previous. Conclusion The quality control of electronic medical records reduces the occurrence of medical record defects and effectively improves the quality of final medical records.