摘要
目的探讨电子病历质量控制对减少血管外科电子病历不良事件的应用效果。方法选取2017年8月1日-2018年12月31日期间,某院血管外科病历134份,以电子病历质量控制实施时间为节点,分为实施前组(61份)和实施后组(73份),比较实施前后不良事件发生率和护理缺陷发生率,并比较电子病历质量控制实施前后环节质控结果反馈耗费时间和病案质量评分情况。结果电子病历质控实施前后分别发生缺陷记录28份和7份。电子病历质控实施后护理缺陷记录发生率(9.59%)明显低于实施前(45.90%),差异有统计学意义(χ^2=22.707,P=0.000)。质控实施后,环节质控结果反馈耗费时间明显少于实施前,病案质量评分明显提高,差异有统计学意义(t=34.860、-13.370,P=0.000)。结论对血管外科实施电子病历质量控制有助于减少不良事件,减少护理缺陷,有全面、高效、及时、互动等优点,提高了护理电子病历质量,值得进一步推广。
Objective To explore the application value of electronic medical record quality control in vascular surgery nursing.Methods 134 copies of vascular surgical medical records were selected during August 1, 2017 and December 31, 2018, electronic medical record quality control implementation time for the node, divided into implementing group(61) before and after the implementation of group(73), the incidence of adverse events before and after the comparison and the incidence of nursing defects, and compare the electronic medical record quality control before and after the implementation of link quality control results feedback time consuming and medical record quality rating.Results There were 28 nursing defects and 7 nursing defects before and after the implementation of electronic medical record quality control. The incidence of nursing defects(9.59%) after the implementation of electronic medical record quality control was significantly lower than that before the implementation(45.90%), the difference was statistically significant(χ^2=22.707, P=0.000). After the implementation of quality control, the feedback time of quality control results was significantly less than that before the implementation, and the quality score of medical records was significantly improved, with statistically significant difference(t=34.860,-13.370, P=0.000).Conclusion The implementation of electronic medical record quality control is helpful to reduce adverse events, reduce nursing defects, comprehensive, efficient, timely, interactive and other advantages, improve the quality of nursing electronic medical record, is worth further promotion.
作者
范丽颖
王磊
潘易飞
高春城
Fan Liying;Wang Lei;Pan Yifei;Gao Chuncheng(Vascular Surgery,First Affiliated Hospital of Harbin Medical University,Harbin 150001,Heilongjiang Province,China;不详)
出处
《中国病案》
2020年第8期14-17,共4页
Chinese Medical Record
关键词
电子病历
质量控制
血管外科
护理工作
应用价值
Electronic medical records
Quality control
Vascular surgery
Nursing work
Application value
