中小型医院电子病历书写质量控制系统的研究与应用

Small and Medium-sized Hospitals to Write Electronic Medical Records System of Quality Control and Application

自20世纪80年代以来,信息技术蓬勃发展,己在社会的各个领域得到广泛应用,随着医学科技快速发展和医疗设备不断更新,医院管理更加复杂和困难,对医院管理的科学性要求越来越高,仅靠管理者的个人经验和传统的手工管理模式,己经远远不能满足现代化医院管理的需要,不能适应医院现代化发展的步伐。建立和应用病历书写时限质量在线控制系统,以期能够准确评价和严格控制病历书写的时限质量。根据《病历书写基本规范》对病历书写时限的规定,应用计算机技术采集、加工、传输和存储病历书写过程的实时信息,建立时限质量在线控制指标体系,设计时限质量在线控制系统。该控制系统的建立和应用,对加强医疗环节质量管理,规范医疗行为,降低医疗缺陷,提高医疗质量起到了十分有效的作用。

Since the 1980s, the development of information technology boom, others in the community, is widely used in various fields, with the rapid development of medical technology and the constant updating of medical equipment, hospital management more complex and difficult, the hospital management requirements of the scientific nature of the increasingly high, the individual alone by managers post-mortem and the traditional manual management style, has been far from meeting the needs of modern hospital management, The establishment and application of medical writing quality time on-line control system with a view to be able to accurately assess and strictly control the quality of the time limit for written medical records. According to the ＂basic norms of written medical records,＂ write the medical history of the time, using computer technology acquisition, processing, transmission and storage of medical records writing process real-time information, the establishment of time limits on the quality control system of indicators, the quality of design time on-line control systems. The control system for the establishment and application of medical links to strengthen the quality and management and standardize medical treatment, reduce medical defects and improve the quality of health care has played a very effective role.