广东省电子病历系统建设现状及对病案质量的影响

doi:10.3969/j.issn.1006-5253.2022.03.015

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Abstract Objective To make a cross-sectional survey of the construction of electronic medical records and the quality of medical records in public hospitals in Guangdong Province with field research, and to evaluate the influence of the construction of electronic medical record system on the quality of medical records.Methods Thirty-seven experts in the fields of medical record quality control, medical record management and hospital information from the Guangdong Provincial Health Commission Affair Center and 18 tertiary hospitals in Guangdong Province formed 10 groups to assess the levels of electronic medical record system and the quality of inpatient medical records of 60 hospitals in 20 prefecture-level cities in Guangdong Province. Medical records were divided into groups according to the electronic medical record rating and the informatization status of quality control, and the quality of medical records between groups were compared.Results Two hundred and thirtynine medical records from 23 tertiary hospitals were sampled in this survey, with a grade A rate of 97.49%; 390 inpatient medical records from 37 secondary hospitals were sampled, with a grade A rate of 97.18%. The electronic medical record system of 23 tertiary hospitals were rated at level 3 and above, and there was no hospital with electronic medical record system rating of level 5 among 37 secondary hospitals. Manual integrated information system quality control was adopted in 69.6% of the tertiary hospitals, and in 27.0% of the secondary hospitals. The analysis showed that there was no statistical difference in the medical record quality scores of different -electronic-medical record system rating groups (H=1.113,P>0.05 ), while the medical record quality score of the manual combined information system group was higher than that of the manual quality control group (Z=-2.894,P<0.01 ).Conclusion The informatization of medical record quality control can effectively improve the quality of medical records, and it is necessary for hospitals to take it as an important part of the construction of electronic medical record system.

Key words： electronic medical record rating informatization medical record quality public performance appraisal

Received: 14 February 2022

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	Articles by authors
	Lu Jianjun
	Xin Ziyi
	Yu Junrong
	Xiong Ying

Cite this article:

Lu Jianjun,Xin Ziyi,Yu Junrong, et al. Current situation of the construction of electronic medical record system in Guangdong Province and its influence on the quality of medical records[J]. journal1, 2022, 29(3): 228-231.

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http://manu58.magtech.com.cn/Jwk_zgyytj/EN/10.3969/j.issn.1006-5253.2022.03.015 OR http://manu58.magtech.com.cn/Jwk_zgyytj/EN/Y2022/V29/I3/228

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