中医运行电子病历质量的现状分析

目的了解中医运行电子病历的质量现状,分析运行病历存在的缺陷,探讨提高中医电子病历质量的有效方法。方法应用电子病历系统对随机抽取的1000份运行中医病历进行实时监控,以入院记录、首次病程记录、病程记录、知情同意、医嘱、辅助检查、中医内容完整性等为质控指标,进行评价。对监控过程中出现的问题,进行统计分析。结果 1000份病案资料中,甲级病历877份,乙级病历123份,无丙级病历,病历甲级率为87.7%;入院记录发生缺陷最多;中医辨证问题最为突出。结论重视中医运行病历的规范化管理,是提高中医院医疗质量,确保医疗安全的前提,是发展中医药,提高中医学生培养的重点。

The Current Situation Analysis on Running Electronic Medical Record Quality of Traditional Chinese Medicine

Objective To know about the current situation of running medical record quality of traditional Chinese medicine;to analyze the existing defect of running medical record;to investigate the effective method on improving the electronic medical record quality of tradition Chinese medicine.Methods Having real-time monitoring on 1000 running medical record of traditional Chinese medicine selecting randomly through using electronic medical record system;having evaluation by using admission record,the first course of disease record,course of disease record,informed consent form;doctor＇s instruction, auxiliary examination and the completeness of tradition Chinese medicine content as quality control indexes;having statistical analysis on the problem during monitoring.Results In 1000 medical record,877 are class A,123 are class B,none is class C,the rate of class A medical record is 87.7%;the average defect number in non-operation departments and operation department is respectively 0.8 and 1.2;the defect rate of admission record ranks first;the dialectical problems of traditional Chinese medicine are most serious.Conclusion To attach importance to the standardization management of running medical records of traditional Chinese medicine is the premise of improving medical quality of traditional Chinese medicine hospital and ensuring the medical safety;it is the key point of developing traditional Chinese medicine and improving traditional Chinese medicine students training.