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目的研究电子病历在脑出血患者病案管理中的运用。方法 40例脑出血患者应用电子病历来进行病案管理,设为A组;40例脑出血患者使用电子病历前的纸质病历进行病案管理,设为B组。比较两组脑出血患者病案管理工作各项目的效率。结果 A组一周归档率为87.50%、疾病和手术编码正确率为97.50%,均高于B组的7.50%、85.00%,差异具有统计学意义(P<0.05)。A组全月出院病案签收结束日期、首页录入时间、完成病案借阅时间、病案复印时间、封存和解封时间均较B组有所缩短。结论在脑出血患者的病案管理中,应用电子病历能够提高工作的效率。
Objective To study the application of electronic medical records in case management of patients with cerebral hemorrhage. Methods 40 patients with cerebral hemorrhage were treated with EHR for case management. Group A was enrolled in this study. Forty cerebral hemorrhagic patients were treated with medical records before the EHR. The efficiency of each item in case management of cerebral hemorrhage in two groups was compared. Results The rate of one-week filing in group A was 87.50%, and the correct rate of disease and surgical coding was 97.50%, which were all higher than those in group B (7.50%, 85.00%). The difference was statistically significant (P <0.05). Group A full-month discharge record the end of the record date, the first page entry time, the completion of medical record borrowing time, medical record copying time, sealing and unwinding time than the B group has been shortened. Conclusion In the case management of patients with cerebral hemorrhage, the use of electronic medical records can improve the efficiency of the work.