Electronic medical records inaccurate monitoring data Analysis and Countermeasures.docVIP

 PAGE \* MERGEFORMAT 7 Electronic medical records inaccurate monitoring data Analysis and Countermeasures Of: Liu, Peng Shasha, Ren Yu Jiang, Guo Kunhua, pay Hao, Wang Mei [Keywords:] electronic medical records and Countermeasures inaccurate monitoring data Physicians to write electronic medical records as a convenient tool for medical records [1,2], although supporting the monitoring of statistical systems, but it can also monitor the statistical data appear inconsistent with the actual situation, the data quality management for the loss of quality control records practical significance. how to monitor the results look reasonable and find the reasons for inaccurate data, to take appropriate quality control measures is the primary task of the staff. Analysis 1 Our hospital in April 2007 Military version 2.2.8 PASS enabled electronic medical record (Tianjian Military Hospital Information System, XML editor, and record quality to use 2.0.0 version 1.1.4 version control system and electronic medical records management sub-system, Operation in inaccurate statistical data monitoring the situation with the clinicians and Information Section after the staff found the crux of communication are as follows: Select the template is not in accordance with the requirements of 1.1. Such as: (1 records do not choose to save the template and save records written in the course of the record, (2 diagnosis, drug analysis, efficacy analysis system recorded the corresponding template is not written in the course of writing the record, or written records in the course of drug analysis, efficacy analysis, but not in the medical record automatically when you save the pop-up “progress note subtitled” window, select the appropriate title. because of the strict monitoring standards of statistical systems, the corresponding module is not written, The system default is not content to write and points deduction, resulting in lower scores. 1.2 The patient is discharged,