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目的加强病历书写时限质控,提高病案质量,保障医疗安全。方法利用电子病历系统,对2012年1-12月份10595份运行病历的入院记录、首次病程记录、医嘱、手术记录的书写时限进行监控。结果经过一年多以来持续不断地周周检查、通报、整改、反馈,并落实奖惩措施,使病历书写及时率从56.25%提高到93.2%,明显改善。结论利用电子病历系统可以有效地监控病历完成时间,从而加强病历质量的环节管理,提高病历质量。
Objective To strengthen the quality control of medical record writing time limit, improve medical record quality and ensure medical safety. Methods The electronic medical records system was used to monitor the writing time of the records of the first visit, the record of the first course, the doctor’s orders and the surgical records of 10,595 medical records from January to December in 2012. Results After more than a year of continuous inspection, notification, rectification and feedback, and implementation of rewards and punishments, the time and rate of medical records writing increased from 56.25% to 93.2%, which markedly improved. Conclusion The use of electronic medical record system can effectively monitor the completion time of medical record, so as to strengthen the link management of medical record quality and improve the quality of medical record.