Analysis of the Use of Electronic Medical Records in the Management of Borrowed and Copied Cases and the Impact of Archiving Quality Control
Objective To explore the application of electronic medical records in the management of borrowed and copied medical records in maternal and child health centers,and to analyze the impact of archiving quality control.Methods A total of 680 medical records from the medical record room of Fuzhou Maternity and Child Health Care Hospital from July 2020 to August 2022 were selected as the research subjects.340 traditional handwritten medical records implemented from July 2020 to July 2021 were included in the control group,and 340 electronic medical records implemented from August 2021 to August 2022(new system launched in October 2021)were included in the observation group.The quality scores of medical records in different groups,the defect rate of medical record writing,and the convenience rate of nursing staff in using medical records were compared.Results The observation group's medical record homepage,admission records,course records,discharge records,treatment,auxiliary examinations,basic requirements and medical orders,as well as total scores,were(2.70±0.46)points,(23.24±1.35)points,(32.45±2.88)points,(4.50±0.60)points,(5.20±0.50)points,(5.50±0.50)points,(8.85±1.21)points,and(82.44±5.46)points,respectively;The control group was divided into(2.00±0.01)points,(20.81±1.13)points,(29.54±1.84)points,(3.64±0.66)points,(3.90±0.30)points,(4.00±0.45)points,(7.76±1.25)points,and(71.66±4.56)points,respectively,it was higher in observation group(P<0.05).The defect rates of basic nursing in the observation group were 3.24%,4.12%,2.94%,2.35%,2.65%and 2.06%,respectively,such as omission of basic nursing,failure to reflect specialty conditions,untimely nursing records,inaccurate condition assessment and description,inconsistency between vital signs and body temperature sheets,and inconsistency with physician records.The control group was 6.76%,9.41%,6.47%,5.59%,6.18%,5.00%,and the observation group was lower than the two groups(P<0.05).The medical record borrowing time(2.51±0.85)min,medical record copying time(5.24±1.89)min,and home page entry time(3.33±0.89)min in the observation group were shorter than those in the control group(6.41±1.54)min,(9.42±2.47)min,(6.66±1.63)min(P<0.05).Conclusion The use of electronic medical records in the management of borrowing and copying medical records in maternal and child health centers is beneficial for improving the quality of medical records,reducing the rate of medical record writing defects,and improving the convenience of nursing staff in using medical records.
electronic medical recordshandwritten medical recordsmaternal and child health care hospitalmedical record managementarchival quality controlquality of medical recordsmedical record writing
万方数据
维普
