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目的调查并分析临床医护人员对电子病案系统的认识以及应用该系统后对临床工作产生的影响。方法对某综合性三甲医院的临床医护人员进行问卷调查。内容包括:医护人员对电子病案系统应用前后临床工作的变化,对相关规范的理解、应用现状的满意程度、对电子病案系统的优势及不足的认识。结果 92.58%的被调查人员认为应用该系统可以提高工作效率;医师对应用电子病案系统的整体满意度高于护士。41.11%的被调查者认为电子病案对临床工作仍存在一定的负面影响。结论电子病案的应用在临床工作中显示出了明显的优势,但使用者也反映了其存在的一些问题。应通过改善操作系统、强化培训、完善疾病模板、加强质量监控等多种措施提高临床医疗质量。
Objective To investigate and analyze the understanding of clinical medical staff on the electronic medical record system and the impact on the clinical work after the system is applied. Methods A questionnaire survey was conducted on the clinicians in a comprehensive top three hospital. The content includes: the changes of clinical work before and after the application of electronic medical record system by medical staff, the understanding of related norms, the satisfaction of application status, and the recognition of the advantages and disadvantages of electronic medical record system. Results 92.58% of the respondents think that using this system can improve work efficiency; physicians are more satisfied with the application of electronic medical record system than nurses. 41.11% of respondents think that electronic medical records still have certain negative impact on clinical work. Conclusion The application of electronic medical records shows obvious advantages in clinical work, but the users also reflect some existing problems. Improve the quality of clinical care by improving the operating system, strengthening training, improving disease templates, and strengthening quality control.