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目的加强病历书写时限质控,提高病案质量。方法利用电子病历质控系统,对2013年7月至2013年9月入院记录和首次病程记录的书写时限进行检查。结果经过三个月连续检查、反馈、培训、落实扣罚措施,病历书写及时率持续提高。7-9月份首次病程记录的按时完成率分别为95.4%、98%、98.6%;7月-9月份入院记录按时完成率分别为95.7%、96.4%、96.7%。结论应用电子病历质控系统监控病历完成时间,有效地促进了病案质量的提高。
Objective To strengthen the quality control of medical record writing time limit and improve the medical record quality. Methods The electronic medical record quality control system was used to check the writing time limit of admission records and first course records from July 2013 to September 2013. Results After three months of continuous examination, feedback, training, implementation of deductions and punishments, the medical records writing rate continued to improve. The completion rates of first-course records from July to September were 95.4%, 98% and 98.6%, respectively. The completion rates of admission from July to September were 95.7%, 96.4% and 96.7%, respectively. Conclusion The application of electronic medical record quality control system to monitor the completion time of medical record effectively promoted the improvement of medical record quality.