摘要
目的 通过分析住院检查报告单电子化对归档效率的影响,为提高住院病案归档质量提供参考.方法 采集2023年1月1日-2023年12月31日某三甲医院住院电子病案管理系统中已归档病案神经内科1100份和神经外科555份.比较2023年1月1日-2023年6月30日与2023年7月1日-2023年12月31日出院归档纸质报告的种类、例数,以及归档日期距出院日期的天数.结果 患者出院后归档的纸质报告减少275份,下半年相比上半年减少了 28.5％.出院后临床科室将纸质报告归档到病案室的日期距出院日期的天数,下半年与上半年相比差异不明显,平均从12.9天下降到12.1天(Z=-0.078,P=0.938＞0.05),但纸质报告电子化后系统归档缩短超一半时间.结论 住院检查报告直接电子化归档,有助于提升检查报告归档效率,应加快将住院检查报告电子化归档的进程.
Abstract
Objectives This stud aims to analyze the impact of electronic inpatient examination report forms on filing efficiency,providing a reference for improving filing quality.Methods Archived medical records in the electronic medical record management system of a tertiary hospital from January 1,2023 to December 31,2023 were collected,including 1,100 records from the Department of Neurology and 555 records from the Department of Neurosurgery.The types and number of paper reports archived between January 1,2023,and June 30,2023,and between June 30,2023,and December 31,2023 were compared,as well as the number of days from the archive date to the discharge date.Results The number of paper reports filed after patients were discharged from the hospital decreased by 275,a 28.5％decrease in the second half of the year compared to the first half.There was no significant difference in the number of days from the discharge date to the date when the clinical paper report was filed in the medical record room in the second half of the year compared with the first half of the year,which decreased from 12.9 days to 12.1 days on average(Z=-0.078,P=0.938＞0.05).However,the time for filing paper reports in the system was shortened by more than half after they were digitized.Conclusions Direct electronic filing of inpatient examination reports helps improve the efficiency of filing examination reports,and the process of electronic filing of inpatient examination reports should be accelerated.
维普
万方数据