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目的探讨通过屏幕截图进行电子病历环节质控的方法在提高病案书写质量中的效果。方法随机抽取2011年7月至2013年6月两年内共3960份运行病历进行质量监控(程序监控辅以人工检查),前12月的检查结果以文本形式反馈给医师,后12个月质控检查时增加对病历缺陷进行屏幕截图,检查结果以图片加文本形式反馈给医师,最后对屏幕截图实施前后每月存在的各种类型缺陷数量进行统计分析。结果通过屏幕截图法进行病历质量监控后病案缺陷的数量比屏幕截图前明显减少(P<0.01)。结论通过屏幕截图进行电子病历环节质控能有效减少病案缺陷,明显提高病历质量。
Objective To explore the effect of quality control of electronic medical records through screenshots in improving the quality of medical record writing. Methods A total of 3,960 medical records were monitored during the two-year period from July 2011 to June 2013 for quality control (program monitoring supplemented by manual inspection). The results of the previous 12 months were returned to the physician in text form. After 12 months, the quality control During the examination, a screen shot of the medical record defect is added. The test result is fed back to the physician in the form of an image plus a text. Finally, statistical analysis is performed on the number of various types of defects existing before and after the screen shots are implemented. Results The number of medical record defects was significantly lower than that before the screenshot (P <0.01). Conclusion The quality control of EHR through screen capture can effectively reduce the number of medical record defects and significantly improve the quality of medical record.