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Through the practice of outpatient doctor station cored by the outpatient Electronic Medical Records (EMR),the paper discusses the disadvantages of outpatient paper medical records and the advantages of outpatient EMR,summarizes the key points and difficulties in promoting outpatient EMR,and meanwhile points out to pay attention to the integration with other information system,data standardization,perfection of the management system,integrated consultation system and other issues in the practice process.
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Objective:To evaluate the reliability and validity of the Clinical Reception Attitude Scale .Meth-ods:Based on the survey of 311 outpatients from 4 first-class hospitals , the test-retest reliability , internal con-sistency , construct validity , criterion validities and discriminant validity of the scale was tested .Results:The test-retest reliability was 0.901, the internal consistency was 0.973, 4 common factors accounted for 80.0%of the total variation, the items of which matched the construct of the scale , the criterion validities were 0.856 and 0 .810 , the discriminant validity was good .Conclusions: The results indicated the Clinical Reception Attitude Scale had good reliability and validity .The adjusted scale is an effective tool for the investigation of clinical recep-tion attitude of doctors in China .
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El eje de la auditoria médica es una historia clínica adecuadamente confeccionada. La historia clínica es la constancia escrita detodos los exámenes médicos, estudios realizados y tratamientos aplicados durante el transcurso de la enfermedad.Objetivo:Evaluarla calidad de registro de las historias clínicas de Consultorios Externos del Servicio de Medicina Interna en la Clínica CentenarioPeruano Japonesa.Diseño:Descriptivo de corte transversal.Lugar: Consultorios externos del Servicio de Medicina Interna de laClínica Centenario Peruano Japonesa.Material:Historias clínicas de pacientes atendidos en la consulta externa del Servicio deMedicina Interna.Métodos:Se evaluó 323 historias clínicas mediante un muestreo aleatorio simple, las cuales fueron sometidasa una ficha de auditoría que comprendía 10 ítems, cada uno calificado con 10 puntos, para un total de 100 puntos: fecha y horade atención, pulcritud y legibilidad, anamnesis adecuada, signos vitales, examen físico, diagnóstico, plan de trabajo, exámenesauxiliares, tratamiento completo...
Core of medical audit is a properly tailored medical history. The medical record includes all medical examinations, studies conducted and treatments applied during the course of the disease. Objectives: To assess medical records registration quality of Internal Medicine doctors offices at Clinica Centenario Peruano Japonesa. Design: Descriptive cross-sectional study. Location: Internal Medicine outpatient offices at Clinica Centenario Peruano Japonesa. Material: Clinical records of patients attended in Internal Medicine doctors offices. Methods: Three hundred and twenty-three medical records were collected by random sampling and subjected to a 10-items record audit, each rated at 10 points, for a total of 100 points. Items included date and time of care, neatness and legibility suitable record, vital signs, physical examination, diagnosis, plan of work, laboratory findings, complete treatment, and signature and stamp of the physician. Records with total score more than or equal to 80 were rated as acceptable, and all others as need to improve. Main outcome measures: Acceptable or need to improve medical records. Results: Two hundred and six (63.8 per cent) clinical records were rated as acceptable and 117 (36.2 per cent) as need to improve. Items diagnosis and complete treatment presented poor registry more frequently, both in records with acceptable registry (filled in completely in 64.6 per cent and 62.6 per cent respectively) and those with need to improve registry (20.5 per cent and 23.1 per cent respectively). Signature and seal of the attending physician were the best items in both categories (99.5 per cent and 93.2 per cent respectively). Conclusions: More than half of the medical records had an acceptable quality at the Clinica Centenario Peruano Japonesa.
Asunto(s)
Atención Ambulatoria , Auditoría Médica , Control de Formularios y Registros , Registros Médicos , Estudios Retrospectivos , Estudios TransversalesRESUMEN
As an important component of hospital information system (HIS), outpatient information management system (OIMS) should be emphasized on during the process of hospital digitalization. This paper summarizes the main contents and functions of OIMS and discusses the most important sub-system of OIMS's, outpatient doctor workstation, on its case history, examination/Lab and prescription. The generalpurpose card system for outpatient service will be set up on the basis of computerized OIMS, and thus the problems of outpatient can be eliminated completely.