基于电子病历的医疗质量监测与评估

Monitoring and Evaluation of Quality of Medical Care Based on Electronic Medical Record

目的探讨基于电子病历的医疗质量评估体系的构建及面临的问题。方法通过文献回顾,结合多年从事医疗质量监测、管理工作经验,梳理电子病历、临床决策、质量监测之间的关系。结果构建了基于电子病历系统的医疗质量评估体系框架。该框架以临床医务人员工作为核心,以临床辅助决策信息、政策法规信息为参考,在对患者实施诊疗的过程中,对各诊疗环节及指标进行实时监测。在此基础上,形成了评估指标体系,完成了医疗质量的动态评价。结论该评估体系结合临床决策信息,更加注重内在医疗质量的监测和评价,有助于提高医疗质量,减少医疗差错。

Objective The construction of healthcare quality assessment system based on electronic medical record, and the possible problems needed to face were discussed. Method The literature was reviewed, combined with years of experiences engaged in medical quality monitoring, management experience, combing electronic medical records, clinical decision -making, and familiarity with the relationship between quality monitoring. Result The framework of healtbcare quality assessment system based on electronic medical records system was built. The framework regarded clinical medical personnel working as the core, and clinical supporting decision information, policies and regulations as auxiliary. In the implementation of treatment for patients, va- rious aspects and indicators of treatment were real - time monitored. On this basis, the evaluation index system was formed, and the dynamic evaluation of medical quality was realized. Conclusion The evaluation system combined with clinical decision - making information put more emphasis on monitoring and evaluation in the intrinsic quality of medical care, helping to improve medical quality and reduce medical errors.