纸质病案数字化过程的质控对策

Quality Control Countermeasures for Digitized Process of Paper-based Medical Records

目的在纸质病案数字化过程中采取一定的质控对策保证每本病案不被漏扫、扫描后的每本病案页数完整、图片清晰、病案首页索引信息正确以及扫描后病案归档无误。方法通过规范加工流程、设置专人质控等人为干预和系统程序干预两方面同时进行。结果成功地将我院纸质病案从质量和数量上准确无误的实现了数字化。结论病案扫描经过严格的质量控制,有效地保证了病案扫描加工的质量,最大限度地避免了漏扫、数据加工错误、病案弄丢和归包错误等较大问题。

Objective To take some quality control countermeasures to guarantee complete medical records,clear pictures,correct index information on first page as well as correct archiving of medical records after scanning. Methods Digitized process was standardized; meanwhile,interventions including special person in charge of quality control and system program were also implemented. Results Paper-based medical records in our hospital successfully and correctly realized digitization in quality and quantity. Conclusion Strict quality control effectively guaranteed the scanning quality of medical records and minimized a series of big problems,such as omitted scanning,data mistake,medical records loss and archiving mistake etc.