A Study Of The Status Quo Of Electronic Medical Records Operation And Cognition Of It

Objective: The questionnaire survey on the clinicians and medical administrative staffs indicates that to understand the present situation of electronic medical records writing,management,to cognize electronic medical record,and to analyze the potential problems provide useful information for a more rational management system,in order to promote the standardization of medical records and achieve the purpose of improving quality of medical care.Methods: The methodology of the thesis is based on the self-designing questionnaire and field survey.According to the sample size calculation and inclusion exclusion criteria,the investigation is conducted on 450 clinical physicians and 288 medical administrative staffs in four tertiary hospitals in Kaifeng,Henan province.The general demographic data of the respondents,the application of electronic medical records/writing situation,the knowledge of electronic medical records,the problems of electronic medical records and the impact of electronic medical records on medical quality were collected.Different statistical methods are applied,depending on the different characteristics of the data and the purpose of the study.Results: 1.Clinician writing status quo and survey of electronic medical records cognition show:(1)clinician writing status quo: 48.7% physicians directly copy,paste and modify the similar parts of the electronic medical records;ratio(?40%)of copying and pasting accounts for 76.7% physicians.The main reasons for the writing errors lie in the lack of responsibility(38.2%)and poor management of medical record system(29.8%).54.9% physicians could regularly check their medical records,33.1% heads of departments often check electronic medical records.(2)Survey on clinicians' cognition of electronic medical records shows that clinicians believe the first-grade advantage of electronic medical records application is to improve efficiency and next to improve professional skill. Electronic medical records supervision can improve the accuracy of medical records writing,standardization and systematiceness of medical records,prompt law evidence to be the main motivation of clinicians' good medical records writing(32.9%),and cultivate clinical thinking(49.3%).According to clinicians,the first legal issue with which electronic medical records is confronting is the confirmation of hospital management concept,and the second is the modification trace preservation.Over 80.4% clinicians know a little or nothing about the relevant laws or regulations about electronic medical records.53.6% clinicians agree on the punishment system applied in the using of electronic medical records.Clinicians believe that the demand of electronic medical records training is on the highest rate(4.46 ± 0.72),while the negative cognitive average score about the impact that electronic medical records exerts on medical quality is the lowest.2.The status quo of medical administrative staffs and electronic medical records cognition survey show:(1)The status quo of medical administrative staffs: 38.2% staffs often get access to the electronic medical records with writing errors.The first problem they are facing is the high ratio of pasting and copying electronic medical records(43.8%).The next one is delay of relevant signatures or date(24.0%),inaccuracy of medical records description(17.7%)and error writing in the home page of medical records.52.8% staffs ascribe the error writing of electronic medical records to staffs' weaker sense of responsibility.(2)Survey of medical administrative staffs' cognition of electronic medical records shows that 70.8% officers believe the quality of electronic medical records mainly lies on their departments control of electronic medical records;over 60% staffs know a little or nothing about the relevant laws or regulations concerning with electronic medical records.About 70% staffs don't have good management of electronic medical records system operation,and different staffs have different levels of management of electronic medical records(P=0.031);91.3% staffs believe the application of electronic medical records can improve the efficiency of medical records management;82.3% staffs believe electronic medical records are helpful to improve the quality of medical care;electronic medical records supervision may improve accuracy,normalization and systematicness of medical records,and meanwhile reduce writing speed and promptness of medical records accomplishment.Medical management officers have higher recognition of electronic medical records' influence on medical records management(4.34 ±0.70)and higher cognitive aspects of training needs(4.36 ± 0.75).Conclusion: 1.At present,there are some problems in the operation of electronic medical records.For instance,physicians often copy and paste electronic medical records,and usually make mistakes in electronic medical writing.Besides,they seldom conduct self-examination and department heads cannot enhance their supervision.2.Electronic medical records could help the hospital clinicians and medical management staffs improve work efficiency,professional skills,comprehensive quality,scientific research ability and so on.3.There are insufficiencies in the relevant cognition on electronic medical records and related laws and regulations.Suggestions: 1.To improve and perfect the existing quality control standards of electronic medical records,and to increase the quality control standards aiming at common problems in electronic medical records.2.To strengthen clinicians and medial administrative staffs' cognition of electronic medical records,especially the related laws and regulations.3.To perfect electronic medical records management system,ensuring the scientificity and legality of hospital system.Meanwhile,to carry out staff training and the effect of training should be ensured.