电子病历和传统手写病历的质量比较及评价

摘要

Objective Through the comparative analysis of the quality between electronic medical records and traditional handwritten medical records, explore the problems and evaluation in the running of electronic medical records. Methods In the electronic medical records in a hospital from June 2012 to December 2012, 600 were randomly selected as the experimental group,600 cases of hand-written medical records as a control group, do comparative analysis of the two cases of Grade A medical record rate and quality score of each link.Results Electronic medical records defects are higher than handwritten medical records, Grade A medical record rate is lower than the latter. The quality score of hospital records and the course record score are significantly lower than handwritten medical records;writing score is higher than the latter.Conclusion Electronic medical records improve the writing specifications and unity, but easier to make a mistake, and should strengthen online real-time monitoring, the doctor's computer knowledge training and cognition on pitfalls.%　　目的通过电子病历和传统手写病历质量的比较分析，探讨电子病历运行过程中存在的问题并评价应用效果。方法随机抽取某院2012年1月--6月电子病历600份以及该院电子病历实施前半年手写病历600份进行对照分析，比较分析两种病历的甲级病案率和各环节的质量评分。结果电子病历缺陷率高于手写病历，甲级病案率低于手写病历。电子病历的入院记录、病程记录的质量评分显著低于手写病历；书写基本要求环节的评分高于手写病历。结论电子病历虽然提高了书写的规范性和统一性，但更易出现操作失误，应加强网上实时监控、医生相关计算机知识的培训和医务人员对易犯错误的认识。