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中文摘要: 目的：研究江苏某三级公立医院门急诊电子病历书写情况及其影响因素，为进一步推进门急诊电子病历的使用提供参考。方法：收集某三级公立医院2023年2-10月份门急诊相关数据，采用方差分析和多元线性回归分析影响门急诊医师电子病历使用的主要因素。结果：性别、年龄、科室差异、专科模板、每诊疗单元负荷是影响门急诊电子病历使用的关键因素（P＜0.05）。结论：门急诊电子病历的使用情况受性别、年龄、科室分类、专科模板、每诊疗单元负荷的影响，医院应根据不同专科、不同人群制定差异化的措施，通过培养年轻医师临床思维、建立层级质控管理体系、完善电子病历模板、合理设置门诊号源等方式，切实提高门急诊电子病历的使用比例和书写质量。
Abstract:Objective：To study the writing of outpatient and emergency EMR and its influencing factors in a certain tertiary public hospital in Jiangsu Province，in order to provide references for further promoting the use of outpatient and emergency EMR. Methods：The data related to outpatient and emergency departments in a tertiary public hospital from February to October 2023 were collected. ANOVA and multiple linear regression was used to analyze the main factors influencing the EMR of outpatients and emergency physicians. Results：Gender，age，department differences，specialty templates，and workload of each diagnosis and treatment unit were the key factors influencing the signing rate of outpatient and emergency EMR（P＜0.05）. Conclusions：The use of outpatient and emergency EMR is affected by gender，age，department differences，specialty templates，and the workload. Different measures should be implemented for different specialties and populations to improve the use ratio and writing quality of outpatient and emergency EMR through training clinical thinking of young doctors，establishing hierarchical charge management system，improving EMR templates，and reasonably setting outpatient number sources.
keywords: Outpatient and Emergency EMR Workload Clinical Thinking Hierarchical Management Specialized Templates
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基金项目:国家卫健委医院管理研究所医疗质量循证管理持续改进研究项目（YLZLXZ22G011）；江苏省医院协会医院管理创新研究课题（JSYGY-2-2021-140、JSYGY-3-2023-162） 国家卫健委医院管理研究所医疗质量循证管理持续改进研究项目（YLZLXZ22G011）；江苏省医院协会医院管理创新研究课题（JSYGY-2-2021-140、JSYGY-3-2023-162）
引用文本：
陈玲玲,仇永贵,徐 朗,陈亚楠,赵建美*.某三级公立医院门急诊电子病历使用情况影响因素研究△[J].江苏卫生事业管理,2024,35(3):367-371.
CHEN Lingling,QIU Yonggui,XU Lang,CHEN Yanan,ZHAO Jianmei*.Study on the Influencing Factors of the Use of Outpatient and Emergency EMR in a Certain Tertiary Public Hospital△[J].Jiangsu Health System Management,2024,35(3):367-371.
陈玲玲,仇永贵,徐 朗,陈亚楠,赵建美*.某三级公立医院门急诊电子病历使用情况影响因素研究△[J].江苏卫生事业管理,2024,35(3):367-371.
CHEN Lingling,QIU Yonggui,XU Lang,CHEN Yanan,ZHAO Jianmei*.Study on the Influencing Factors of the Use of Outpatient and Emergency EMR in a Certain Tertiary Public Hospital△[J].Jiangsu Health System Management,2024,35(3):367-371.
