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目的分析电子病案现存的质量缺陷,为质量监控提供有针对性的策略;方法随机抽查1521份出院电子病案;结果1521份病案甲级率达90%以上,病程记录的缺陷最多,占21.09%,前15位缺陷占总缺陷的50%以上;结论加大病案质量的监管和处罚力度,抓住病案质量监控的重点和难点。
Objective To analyze the existing quality defects of electronic medical records and provide targeted strategies for quality control. Methods Randomly select 1521 cases of discharged electronic medical records. Results 1521 medical records were rated as over 90%, with the shortest duration records accounting for 21.09% The first 15 defects accounted for more than 50% of the total defects. Conclusion Increasing the supervision and punishment of the medical record quality and seizing the key and difficult points of the medical record quality control.