【摘要】 目的研究OA系统应用对于降低病历缺项率、提高病案归档效率的效果。方法通过OA系统定期分科室发送缺项病历清单和向责任医师推送当天缺项病历短信两项干预措施提高病案质量,通过OA系统收集干预前后有效病案示踪数据388 646条,采用Mental-Haenszel分层卡方分析法和一般线性模型分别对干预前后的缺项情况和缺项归档天数及其效果进行统计分析。结果干预前病历缺项率为10.15%,干预后病历缺项率为5.87%,Mental-Haenszel分层卡方检验干预前后存在显著性差异;干预前缺项病历平均归档天数为4.84天,干预后缺项病历平均归档天数为3.15天,一般线性模型分析表明干预前后存在显著性差异。结论应用OA系统发送缺项病历清单和推送缺项病历短信能够有效降低病历缺项率、提高缺项病历归档效率,最终提高病案质量和管理效率的目的。更多还原

【Abstract】 Objectives To study the application effect of OA system in the decreasing of lacunarity rate and the improvement of medical records archiving efficiency. Methods Two intervention measures were adopted to improve the quality of medical records,the first was to send lacunarity sheet of medical records to different departments through OA system regularly,and the other one was to send messages to the responsible doctors. 388646 effective tracing data of medical records were collected before and after the intervention through OA system. To conduct statistical analysis on the lacunarity situation,archiving days and the effects before and after the intervention with the application of Mental-Haenszel layered chi-square analysis method and general linear model method. Results The lacunarity rate of medical records was 10.15% before the intervention and 5.87% after the intervention,and there was significant difference before and after the intervention with the application of Mental-Haenszel layered chi-square analysis method. The average archiving days of lacunarity medical records was 4.84 days before the intervention and 3.15 after the intervention,and there was significant difference before and after the intervention with the application of general linear model method. Conclusions To send lacunarity sheet and messages of medical records through OA system could decrease lacunarity rate and improve archiving efficiency of medical records,which would finally realize the goal of improving medical records quality and management efficiency.更多还原