| 赵 坚,程华刚,石兴莲,罗 娟,李 元.临床医师对电子病历相关知识认知的调查研究[J].,2017,17(16):3160-3163 |
| 临床医师对电子病历相关知识认知的调查研究 |
| Investigation on Cognition of the Electronic Medical Record by Clinicians |
| 投稿时间：2016-12-08 修订日期：2017-01-25 |
| DOI：10.13241/j.cnki.pmb.2017.16.041 |
| 中文关键词: 临床医师 电子病历 医疗质量 认知 |
| 英文关键词: Clinicians Electronic medical record Medical quality Cognition |
| 基金项目:贵州省教育厅高校人文社会科学研究项目（14SSD004） |
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| 中文摘要: |
| 摘要 目的：了解临床医师对电子病历书写的态度和行为现状以及电子病历管理和对医疗质量的认知等情况，为制定科学的电子病历管理方案提供借鉴。方法：选取两所2所三级甲等和2所三级乙等医院临床医师共计450名进行调查，采用问卷调查医师对电子病例相关知识(如临床医师对电子病例相关法规认知、电子病例监控对电子病历影响及电子病历优点等)的认知和需求。结果：临床医师电子病历总体书写现状调查显示，对于书写电子病历中相似的部分，48.7%(219例)的医师直接复制粘贴再修改；复制粘贴使用比率≥40%占76.7%(345例)；电子病历书写出错原因主要为认为责任心不强(38.2%)和病历系统掌握不到位(29.6%)；促进临床医师按要求写好病历的主要动力为法律证据(32.9%)和培养临床思维(49.1%)；54.9%(247例)医师能对自己的病历进行经常检查；科室负责人对电子病历经常检查的占33.1%(149例)；50%左右人员对电子病历系统操作掌握情况一般；79.33%的临床医师认为电子病历的使用有助于提高医疗质量；临床医师认为电子病历对医疗质量的影响主要是提高病历书写速率、病历完成及时性、管理系统性、病历安全性和患者满意度。结论：临床医师在电子病历书写中复制粘贴比例较高，且对相关的法律法规认识一般，对医院电子病历系统掌握不熟悉，应加大相关内容的培训，更有利于医院电子病历的管理。 |
| 英文摘要: |
| ABSTRACT Objective: To understand clinicians' attitudes toward EMR written and behaviors as well as their cognition of EMR management and medical quality, and to provide references for the development of EMR management program. Methods: 450 clinicians from two tertiary hospitals and two grade ⅲ-a hospitals to get to know their cognition and needs of relevant knowledge concerning with EMR. Results: Clinician electronic medical records of the overall writing status survey shows that for writing a similar part of the electronic medical records, 48.7% (219 cases) of doctors directly copy and paste modified; copy and paste the use of the ratio of ≥ 40% accounted for 76.7% (345 cases); electronic medical record (EHR) of the electronic medical records of the overall writing situation survey, The main reasons for the writing errors were that the responsibility was not strong (38.2%) and the medical record system was not in place (29.6%); the main motivations for clinicians to write medical records were legal evidence (32.9%) and clinical thinking (49.1% ); 54.9% (247 cases) physicians can conduct regular inspection of their medical records; department heads of the electronic medical records often check accounted for 33.1% (149 cases); 50% of the staff of the electronic medical record system operation in general; 79.33% Of clinicians believe that the use of electronic medical records will help improve the quality of care; The effect of EHR on medical quality is mainly to improve the writing speed of medical records, the timeliness of medical record completion, the systematic management of medical records, the safety of patient records and the satisfaction of patients. Conclusion: The number of clinicians who copy and paste during electronic medical writing is in a higher proportion.They are not familiar with the revelent laws and regulations as well as EMR system. The related training should be enhanced to improve the management of hospital electronic medical records. |
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