病案信息技术对医院工作效率及病案管理水平的影响

Objective To analyze the actual implementation effect of medical record information technology in improving hospital work efficiency and medical record management level. Methods The study period was from January 2024 to December 2024, with a total of 178 medical records. During the period from January 2024 to June 2024, the conventional method was applied in the medical records management of the hospital, including 89 medical records, which were named as the control group. From July 2024 to December 2024, medical record information technology was applied in the medical record management of the hospital, which also included 89 medical records, named as the observation group. The effect of the two groups of medical records management was compared and analyzed. Results The revision rate, writing error rate and non-standard writing rate of medical records in the observation group were lower than those in the control group, and the utilization rate of scientific research, medical insurance and patients in the observation group were higher than those in the control group(P<0.05). The scores of admission record, course record, medical order record, nursing record, auxiliary examination record, front page of medical record and discharge record of the observation group were higher than those of the control group(P<0.05). The average archiving duration and average retrieval time of medical records in the observation group were shorter than those in the control group(P<0.05). The job satisfaction scores of medical record management staff in the observation group were higher than those in the control group(P<0.05). Conclusion Medical record information technology can effectively reduce the revision rate, writing error rate and nonstandard writing rate of medical record archiving, improve the utilization rate of scientific research, medical insurance settlement, and patient access, and significantly improve the management level of medical records. It shortens the time required for medical record archiving and retrieval, and enhances the satisfaction of medical record management staff. It is of great significance to improve the work efficiency and medical record management level of hospitals, and is worthy of wide application in hospital medical record management.