构建基于“军卫一号”的电子病历费用审核流程

Construction of Electronic Medical Record Cost Auditing Process Based on "No.1 Military" Project

电子病历的推广有效规范了医生的诊疗标准,在实现医疗系统信息共享的同时,提高了医疗质量和医生工作效率。相对于电子病历在诊疗过程中的广泛应用,其作为患者出院结算费用审核重要依据的利用率却很低,大部分医院都还停留在纸质病历审核阶段,既降低效率,也容易出错,同时还造成了患者排队等候时间过长、纸质病历流转环节增多以及出院结算流程不畅等一系列问题。通过分析传统纸质病历审核模式的弊端,构建使用电子病历费用审核来取代纸质病历,旨在提高出院结算病历审核工作效率和质量,优化患者出院流程。

Popularity of electronic medical records effectively regulates the standards of medical diagnosis and treatment.While achieving information sharing in health care system,it improves the quality of medical care and doctor＇s efficiency.Compared with extensive application of electronic medical records in diagnosis and treatment,electronic medical records as an important basis for cost audit of patients discharged from hospital is less used,while most hospitals stagnate in the stage of paper medical record auditing,which not only reduces efficiency,but also tends to make errors,meanwhile results in a series of problems such as too long waiting line for patients,increased circulation of paper medical records and unsmooth settlement for patients to discharge from a hospital.By analyzing disadvantages of traditional paper-based medical record auditing,the cost audit mode of electronic medical record in lieu of paper-based medical records is constructed to improve efficiency and quality of cost audit and optimize the process for patients to discharge from hospital.