| 摘要: |
| 目的
探讨基于电子病历质控的临床路径管理的实施效果。方法 选择2015年1月至2015年8月于哈尔滨医科大学附属第一院甲状腺乳腺外科接受治疗的244例结节性甲状腺肿患者作为研究对象，根据住院号随机分为观察组（122例）和对照组（122例）。对照组实施一般的临床路径管理，观察组在对照组基础上，实施基于电子病历质控的临床路径管理。对比两组管理效果并进行分析研究。结果 观察组住院时间明显短于对照组，住院费用显著低于对照组，差异均有统计学意义（均P＜0.05）；观察组总满意率达89.34%（109/122），显著高于对照组的76.23%（93/122），差异有统计学意义（P＜0.05）；观察组与对照组相比，病历书写质量的甲级率及乙级率的差异均无统计学意义（P＞0.05）；观察组优良率为86.89（106/122），显著高于对照组的73.77%（90/122），差异有统计学意义（P＜0.05）。结论 基于病历质控的临床路径管理不仅在临床上患者和医护人员都反应很好，高于传统临床路径管理，还减少患者的住院和恢复时间，减轻患者的费用，值得临床进一步推广。 |
| 关键词: 质量控制 电子病历 临床路径管理 结节性甲状腺肿 |
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| Analysis of The Implementation Effect of Clinical Pathway Management Based on the Electronic Medical Record Quality Control |
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| Abstract: |
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Objective
To investigate the effect of clinical pathway management based on electronic medical record quality control. Methods 244 cases of nodular goiter patients from January 2015 to August 2015 in the First Affiliated Hospital of Harbin Medical University were selected as the research object, according to the number of hospitalized were randomly divided into observation group (122 cases) and control group(122 cases). The control group with the general management of clinical pathway, the observation group based on the control group with the clinical pathway management of electronic medical record quality control, compared and analyzed the management effect in two groups. Results The hospitalization time in observation group was shorter than the control group, the cost of hospitalization was significantly lower than the control group, the differences were statistically significant (P＜0.05); the total satisfactory rate in observation group was 89.34%（109/122）, significantly higher than the control group of 76.23%（93/122）, the difference was statistically significant (P<0.05); Observation group compared with control group, the rate of medical record writing quality of class A and class B had no statistical significance (P>0.05); In the observation group, the excellent and good rate was 86.89（106/122, significantly higher than the control group of 73.77%（90/122）, the difference was statistically significant (P<0.05). Conclusion Based on electronic clinical pathway management records quality control not only the patients and the medical care personnel reaction is good than the traditional clinical pathway management, but also reducing recovery time in hospital and patients, reducing the cost of patients, is worthy of further promotion. |
| Key words: quality control,electronic medical record,clinical path management,nodular goiter |
