2007•Chongqing yixueRequires access
Factors influencing electronic medical record quality and countermeasure
Yang Hongtao
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Abstract
Objective To study the countermeasure improving electronic medical record quality after analyzing the causes of defects in the electronic medical records. Methods To extract 6 515 cases of online electronic medical records randomly from January to June in 2006 in a prospective research. The sampling inspection ratio was 21. 3%. Quality control was performed according the Basic Standard of Medical Record Writing and Practice Regulation of Electronic Medical Record Quality Control. Results Imcom plete records in some medical records, which decreased the value of medical records, were found by medical record link quality control. Conclusion It is the key to improve medical record quality and medical quality to establishing the effective quality control system, strengthening the linkquality control of the electronic medical records and improving the whole quality of clinicians.