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为探讨电子病历系统书写入院记录和出院记录的效率,将40位职称同为中级的医生随机分成2组,分别使用电子病历系统方法与传统手工方法书写入院记录和出院记录,全过程实时记录完成入院记录和出院记录各部分的时间。将医生完成入院记录和出院记录的时间换算为速度分数,专家对病历的评分记为质量分数,二者加权后得到综合分数,并对两种方法进行统计分析。结果显示,在书写入院记录的对比研究中,电子病历系统方法组平均总用时为15.02 min,手工书写方法组为43.10min,电子病历系统方法组在完成质量方面总得分高于手工书写方法组,电子病历系统方法组在综合效率方面平均得分高于手工书写方法组,其差异具有统计学意义(P<0.01)。在书写出院记录的对比研究中,电子病历系统方法组平均总用时为4.34min,手工书写方法组为33.32min,电子病历系统方法组在完成质量方面总得分高于手工书写方法组,电子病历系统方法组在综合效率方面平均得分高于手工书写方法组,其差异具有统计学意义(P<0.01)。由此可以看出,电子病历系统能够有效提高书写病历的速度和质量,大大减轻医生书写病历的工作量,书写病历的效率明显优于手工方法。
In order to explore the efficiency of the electronic medical record system in writing admission record and discharge record, 40 doctors and mid-level doctors were randomly divided into two groups. The electronic medical records system and traditional manual methods were used to write admission records and discharge records respectively. The whole process was recorded in real time Admission records and discharge records of various parts of the time. The doctor completed the admission records and discharge records of the time conversion rate points, the medical record of the medical record as the quality score, the two were weighted comprehensive score, and the two methods for statistical analysis. The results showed that in the comparative study of admission records, the average total time spent on the electronic medical records system was 15.02 minutes and that of manual methods was 43.10 minutes. The total score of the electronic medical records system was higher than that of manual methods, The average score of the EHR method group in terms of overall efficiency was higher than that of the manual method group, with a statistically significant difference (P <0.01). In the comparative study of writing discharge records, the average total time spent on the electronic medical record system method group was 4.34 minutes and the manual writing method group was 33.32 minutes. The total score of the electronic medical record system method group in completing the quality was higher than that of the manual writing method group, and the electronic medical record system The mean score of the method group in terms of overall efficiency was higher than that of the handwriting method group, and the difference was statistically significant (P <0.01). From this we can see that the electronic medical records system can effectively improve the speed and quality of written medical records, greatly reducing the workload of doctors writing medical records, the efficiency of writing medical records was significantly better than manual methods.