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目的研究分析电子病案首页缺陷的原因及相应干预对策。方法选取出院患者的1600份电子病案作为研究对象。将未采用干预措施的800份作为对照组,将采用干预措施的800份作为观察组。以相关法律法规为依据,对两组电子病案首页缺陷内容进行归类、统计、对比,同时根据比较结果分析首页缺陷原因。结果对照组800份病案中,缺陷病案220份,缺陷率27.50%;观察组800份病案中,缺陷病案55份,缺陷率6.88%;两组比较差异具有统计学意义(P<0.05)。按缺陷项目统计各项信息显示,两组病案缺陷率排列前三位的均是基本信息错误、疾病诊断选择错误、入院病情判别错误。观察组各项缺陷项目信息的缺陷率均低于对照组,差异具有统计学意义(P<0.05)。结论将建立病案质量控制体系、加强质量管理、加强病案首页填报培训、增强临床医师责任心等干预措施应用于电子病案首页填写中,可以有效控制缺陷率。
Objective To analyze and analyze the causes of the defects in the first page of electronic medical records and the corresponding intervention measures. Methods 1600 electronic medical records of discharged patients were selected as the research object. 800 of the interventions were used as the control group, and 800 of the interventions were used as the observation group. On the basis of the relevant laws and regulations, the defects of the two groups of electronic medical record home page were classified, statistically analyzed and compared, and the causes of the first page defect were analyzed based on the comparison results. Results In the 800 cases of the control group, there were 220 defective cases and the defect rate was 27.50%. Among the 800 cases in the observation group, 55 were defective cases and the defect rate was 6.88%. The difference between the two groups was statistically significant (P <0.05). According to the statistics of the defects, the information shows that the top three of the two sets of the record rate of the medical record are the basic information errors, the wrong choice of the disease diagnosis and the wrong identification of the admission disease. The defect rate of each defect item in the observation group was lower than that in the control group, the difference was statistically significant (P <0.05). Conclusion The system of quality control of medical records will be established, the quality of management, the first page of medical records will be improved, the clinicians’ responsibility will be enhanced, and other intervention measures will be applied to fill in the first page of electronic medical records, which can effectively control the defect rate.