结构化电子病历首页数据在临床应用研究分析

摘要

Objective:Study on the clinical application and analysis of structured electronic medical records in our hospital in last.Methods: Discharged patients data selected from July 2012 to June 2014, using statistical methods for data processing, 8000 case files were divided into two groups: Group A and Group B.Results: After comparing the two groups of two groups of data, and ultimately disease coding accuracy rate 94.88%, fill in the correct rate increased 88.38%, missing rate decreased 4.63%, two groups had no significant difference data; The quality of writing the doctor increased gradually, the error rate tends to be stable, structured clinical application to control.Conclusion: Sequential specification writing medical doctor, scientific analysis of medical record information, the clinical application of structured electronic medical records the error rate is reduced in the operation, improve the accuracy, more standardized, accurate, standardized.%目的：研究医院的结构化电子病历首页数据临床应用效果及分析。方法：采集提取出院患者病历首页数据，随机获取结构化电子病历信息，并抽查8000份病历，将其分为原方案组和运行组进行对比，采用统计学方法进行数据处理。结果：经过数据对比，最终病种编码准确率提高94.88%、正确填写率提高88.38%、漏填率降低4.63%，两组数据相比，无显著性差异；医生书写质量逐渐提高，错误率逐步减少，结构化电子病历的临床应用对错误率起到明显控制作用。结论：循序规范医生书写病历，科学分析病案信息，促使结构化电子病历临床应用，并在运行中降低差错率，提高准确度使其更加规范化、准确化及标准化。