Analysis on structured electronic medical record first page data in clinical application

VernacularTitle:结构化电子病历首页数据在临床应用研究分析
Author: Lin WU ; Yang ZHAO ; Yanli SONG
Publication Type:Journal Article
Keywords: Structured electronic medical record homepage; Clinical application; Research and analysis
From: China Medical Equipment 2015;(12):44-46
CountryChina
Language:Chinese
Abstract: Objective:Study on the clinical application and analysis of structured electronic medical records in our hospital in last.Methods: Discharged patients data selected from July 2012 to June 2014, using statistical methods for data processing, 8000 case files were divided into two groups: Group A and Group B.Results: After comparing the two groups of two groups of data, and ultimately disease coding accuracy rate 94.88%, fill in the correct rate increased 88.38%, missing rate decreased 4.63%, two groups had no significant difference data; The quality of writing the doctor increased gradually, the error rate tends to be stable, structured clinical application to control.Conclusion: Sequential specification writing medical doctor, scientific analysis of medical record information, the clinical application of structured electronic medical records the error rate is reduced in the operation, improve the accuracy, more standardized, accurate, standardized.