基于信息化系统的院内会诊现状的实证分析与评价

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目的通过信息化会诊系统分析某三级甲等医院院内会诊的现状。方法通过院内电子会诊系统分析2015年第一季度该院院内会诊情况,并抽查同时段会诊相关病案300份,了解会诊病历的书写质量。结果第一季度院内会诊总数为2613例,会诊科室前二位分别是心内科和神经内科,其中急会诊为1175例,占44.96%,平会诊为1345例,占51.47%,会诊质量欠佳原因,主要为急会诊10分钟未到达12例,占0.9%,申请科室未掌握急会诊指针26例,占2.1%,会诊医师资质不够11例,占0.7%。会诊病历质量欠佳原因主要为基本信息不完善6例,占2.0%,主要住院经过未写14例,占4.7%,诊断未写或未写全7例,占2.3%,会诊目的未写11例,占3.7%,病程记录未反映会诊意见12例,占4.0%。结论院内会诊是关系到医疗质量和医疗安全的重要诊疗手段,随着医院总体业务量的上升,院内会诊的总量也较大,但在会诊过程及会诊病史书写上均存在着影响会诊质量的问题,为医疗安全留下了隐患,医务管理部门及各级医师都要高度重视,才能提高会诊质量,保障医疗安全。 Objective To analyze the status quo of in-hospital consultation in a tertiary level hospital through the information consultation system. Methods Through the hospital electronic consultation system analysis of the hospital in the first quarter of 2015, the hospital consultation, and spot checks during the same period 300 related medical records to understand the medical records of the consultation. Results The total number of in-hospital consultations in the first quarter was 2613 cases. The top two departments of consultation were cardiology and neurology. There were 1175 cases of emergency consultation (44.96%), 1345 cases of ping-pong consultation (51.47%), and the poor quality of consultation , 12 cases (0.9%) did not reach the emergency consultation for 10 minutes. There were 26 cases (2.1%) who did not have the emergency consultation guideline and 11 cases (0.7%) who lacked the consultation physician qualification. The main reasons for the poor quality of medical records were 6 cases with incomplete basic information (2.0%), 14 cases (4.7%) with no major hospitalization, and 7 cases (2.3%) with incomplete or incomplete diagnosis. The purpose of consultation was not written Cases, accounting for 3.7%, records of the disease did not reflect the views of consultation in 12 cases, accounting for 4.0%. Conclusion In-hospital consultation is an important means of diagnosis and treatment that is related to the quality of medical treatment and medical safety. As the total volume of the hospital increases, the total number of in-hospital consultations is also large. However, the consultation process and the history of medical consultation all affect the quality of consultation Problems, leaving hidden dangers for medical safety, medical management departments and physicians at all levels must attach great importance to improve the quality of consultation, to ensure medical safety.
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