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目的通过对电子病历质量的缺陷进行分析,探讨提高病案质量的有效措施,切实维护各级医院的医疗安全。方法结合天津市肿瘤医院终末病历的质控结果及医疗安全不良事件发生特点进行统计分析。结果在2000份终末病历中存在的缺陷,以复制粘贴模板、病历内容欠缺及各种签名滞后为主,且与医疗安全不良事件发生呈正相关。结论实施有效的电子病案质量改进措施是维护医疗安全的重要保障。
Objective To analyze the defects of the quality of electronic medical records and explore effective measures to improve the quality of medical records so as to effectively safeguard the medical safety of hospitals at all levels. Methods According to the quality control results of terminal tumor records of Tianjin Tumor Hospital and the characteristics of adverse events of medical safety, the statistical analysis was made. Results The defects in the 2000 final medical records were mainly copied and pasted templates, lack of medical records and various signatures lags, and were positively correlated with the occurrence of adverse medical safety events. Conclusion The effective measures to improve the quality of electronic medical records are the important safeguard to maintain medical safety.