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目的分析电子病案缺陷特征,探讨提高病案内涵质量措施。方法对医院2010年下半年1300份电子病案的环节质量与终末质量缺陷进行比较分析。结果病案环节质量的缺陷数是1500处,终末病案缺陷数580处。环节质量缺陷率比终末质量缺陷高,两组比较有差异有统计学意义(χ2=32.4,P<0.05)。结论病案环节质量监控比较薄弱,病案环节质量缺陷问题突出,加强病案室质控组力量,强化科室三级实时监控网,实现环节质量控制与终末质量控制并重,是提高病案内涵质量的关键。
Objective To analyze the characteristics of electronic medical records defects and explore measures to improve the quality of medical records. Methods The quality and final quality defects of 1300 electronic medical records in hospitals in the second half of 2010 were compared. As a result, the number of defects in the quality of medical records was 1,500, and the number of defects in the final medical records was 580. The quality defect rate of the link was higher than the final quality defect. There was a statistically significant difference between the two groups (χ2=32.4, P<0.05). Conclusion The quality control of the medical record link is relatively weak, the quality defect of the medical record link is prominent, the strength of the quality control team of the case control room is strengthened, and the real-time monitoring network of the department’s three levels is strengthened. Both the link quality control and the terminal quality control are important, which is the key to improving the connotation quality of the medical record.