目的 探讨电子病历系统的应用对病案质量的影响.方法 选择某院2015年5月-2016年6月3940份电子病历,选择电子病历实施前2012年1月-2012年12月 的3765份纸质病案,对全部病案进行分析,比较实施电子病历系统前后的质量缺陷率,归纳质量缺陷的原因,并提出对策.结果 电子病历组的总缺陷率为16.23%,纸质病案组的总缺陷率为19.01%,电子病历组的总缺陷率明显低于纸质病案组,差异有统计学意义(P<0.05).电子病历组外科、其他科室病案缺陷率均低于纸质病案组,但差异无统计学意义(P>0.05).640份质量缺陷电子病历总共缺陷1149例次,716份质量缺陷纸质病案总共缺陷1790例次,电子病历组缺陷例次低于纸质病案组,差异有统计学意义(P<0.05).结论 实施电子病历系统有利于提高病案质量,但要注意完善电子病历系统的质控功能,对病案加大管理力度.%Objective To explore the impact of the application of electronic medical record system on the quality of medical records. Methods 3940 electronic medical records from May 2015 to June 2016, and 3765 paper medical records before the implementation of electronic medical records from January 2012 to December 2012 were selected and analyzed, and the quality defect rate before and after the implementation of the electronic medical record system was compared, and the reasons of the quality defects were summarized. Results The total defect rate of the electronic case group was 16.23%, the total defect rate of the paper case group was 19.01%, the total defect rate of the electronic case group was significantly lower than that of the paper case group, the quality defect rate of medical case is lower than that of paper case,the difference was statistically significant(P<0.05).Electronic case group surgery, other departments were less than the rate of medical record case group, but the difference was not statistically significant(P>0.05).640 cases of quality defects in the case of electronic medical defects 964 cases, form defects in 185 cases,the difference was statistically significant(P<0.05).Conclusion The implementation of electronic medical record system is conducive to improving the quality of medical records, but should pay attention to improve the electronic patient system defects, increase the management of medical records.
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