18所医院电子病历质量评估

Quality Assessment on the Electronic Medical Records of 18 Hospitals

北京军区联勤卫生部组织对辖区18所医院的电子病历进行抽查,结果提示:质量管理部门对病历质量监控要做到人员落实,并有一定的抽查数量标准;由于质检人员不可能具备多专业技术知识,科室的专业质控更加必要。除时限及格式要求之外,病历内涵质量更加重要。电子病历监控程序设计对内容完成时限有很好的警示和自动质控功能,但不能很好地评价内涵质量的优劣,因此人工质控不可或缺。病案首页信息的时效性和准确性取决于病案三日归档,是病案管理的重要内容之一。无论何种版本,要充分开发、使用监控软件的功能,才能提高病历质量监控的效率和质量。

We made a spot -check of 18 military hospitals electronic medical records in Beijing military area command. The results suggested that the department of quality management must ensure specific staff and minimum sampling standards of supervision of quality. Because inspecting officers could not possess much more special knowledge, the professional quality control must be more necessary. Medical records connotation was more important than the time limit and required format. The program of electronic medical records supervision could automatically warn and control the on - time complete of the medical records, but not evaluate the content medical records. Therefore, manual supervision was indispensable for the quality control of medical records. It was one of important contents of quality management of medical records that effectiveness and accuracy of inpatient information which depended on case history archiving - in - 3 - day. No matter which version of supervision software was used, the software function need to be fully developed and used to improve the efficiency and quality of medical record supervision.