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目的分析某三甲医院急诊留观计算机打印病历的质量缺陷,探讨急诊留观病案的现状,为向电子病历过度做好准备。方法以卫生部病历书写基本规范为标准,对某三甲医院急诊留观2013年1月-2014年4月16个月的病案进行质量分析。结果 4856份急诊留观病案中,缺陷病案1235份,缺陷率25.43%。主要存在问题包括病程记录中使用复制粘贴现象严重,不同上级医师查房记录雷同,占23.08%。另外,医师审签工作滞后,占31.4%,病历归档时间滞后,占21.13%。结论现阶段急诊留观病案与真正意义上的电子病历还有一段距离,通过开发使用真正意义的急诊留观电子病历系统,从根本上解决存在的问题,切实提高病案质量。实现病案为临床、科研等方面服务的目的。
OBJECTIVE: To analyze the quality defects of computer records of medical records of emergency attendants in a top three hospital and to discuss the current status of emergency medical records in order to prepare for the overuse of electronic medical records. Methods According to the basic norms of medical records writing of the Ministry of Health, the quality of medical records of a top three hospital from January 2013 to April 2014 was analyzed. Results In 4856 emergency cases, there were 1235 defective cases and the defect rate was 25.43%. The main problems include the use of copy and paste in the course of disease record is serious, the same physician ward round the same records, accounting for 23.08%. In addition, the physician’s lagged audit work, accounting for 31.4%, medical records filing time lag, accounting for 21.13%. Conclusions At present, there is still a long way to go to observe the emergency cases and the actual electronic medical record. By developing and using the true emergency electronic watch system, we can fundamentally solve the existing problems and improve the quality of medical records. To achieve medical records for clinical, scientific research and other services.