9088份电子病历运行质量分析

摘要

目的：探讨运行电子病历缺陷的原因及管理对策。方法2014年1—12月对医院9088份运行电子病历书写质量进行了检查分析。结果共检查出缺陷1123个，问题涉及病历完成时限、错误拷贝和内涵质量三个方面。这三类问题在手术科室、非手术科室普遍存在。结论运行电子病历检查是监控病历书写时限、改进病历内涵质量的有效措施。%Objective To explore the cause and management countermeasure for defect running of elec-tronic medical records.Methods 9 088 running electronic medical records were checked form January 2014 to December 2014.Results 1 123 defects items were existed, which included writing time limit, mistake copies and connotation quality.These problems widespread in surgical and non -surgical departments.Conclusion The quality control for running electronic medical records is the important methods for monitoring the accomplish time of medical records and promoting the connotation quality of medical records.