摘要
某基层医院在信息化进程中对传统病案质控流程进行升级改造,形成了事前建立质量控制标准规则、事中进行运行病案质控、事后终末质控的闭环病案质控管理流程。新流程强化了质控管理手段,使病案质控更加科学、合理,提高了病案质量,保障了医疗安全,提升了质控人员的工作效率。在对新质控流程使用过程中存在的雷同病历、病历时效性差、越级使用签名等病案质量问题进行梳理与分析后,思考基层医院病案质控问题的原因,并根据某院的实际情况在行政管理、职业教育和软件技术层面提出解决措施。研究旨在使用科学的手段加强病案质量管理,探索基层医院电子病历质控的合理方式,在完善管理模式的基础上加强电子病历的信息化建设进程,更好地提高病案的开发利用价值,从而为患者、医院和社会提供多方面的服务。
In a primary hospital,we made upgrading on the traditional medical records quality control in the process of informatization,formed to establish quality control standard rules before,conducted quality control of medical records during the process and making closed-loop medical record quality control management process of terminal quality control. The new process strengthened the quality control management method,made the medical record quality control more scientific and reasonable,improved the quality of medical records,ensured the medical safety,improved the quality control personnel work efficiency. The problems included similar records,poor timeliness of medical records,skip a grade signature medical records quality and so on existing in the new quality control processes were sorted out and analyzed,the reasons of medical record quality control in primary hospitals were analyzed,and proposed solutions from aspects such as administrative management,vocational education and technical software according to the actual situation of the hospital. The research aimed to strengthen the quality management of medical records by scientific means,explored a reasonable way electronic medical record quality control in primary hospital,strengthened the process of informatization construction of electronic medical records on the basis of the improvement of the management modes,improved the development and utilization value of medical records,so as to provide various services to patients,hospitals and the society.
出处
《中国病案》
2016年第9期20-22,共3页
Chinese Medical Record
关键词
质控流程
电子病历
质控
Quality control process
Electronic medical record
Quality control
