在电子病案模式下建立医疗质量管理系统

Building Medical Quality Management System under Electronic Medical Record Mode

目的在电子病案模式下建立医疗质量管理系统,实时监控病历书写录入质量、内容完整和完成及时性。方法以《病历书写基本规范》内容作为病案质控管理的规范标准要求。对患者从门诊检查至入院治疗到出院及病案归档结束,对病历书写提醒、修改及完成情况进行全程的智能触发提醒和检查。结果基于电子病案的医疗质量管理系统突破了传统的手工对医疗行为和病案质量进行质控、监测、评价的应用范围。将信息化技术应用到了实时性很强的医疗质量管理活动中,全面提高了工作效率和医疗质量,取得了很好的应用效果。结论建立完善的医疗质量管理系统,为医院监控和管理电子病案提供了有效的管理途径,让医疗质量管理工作更便捷、到位。

Objective Under electronic medical record mode,medical quality management system are built in order to real-timely monitor input quality of medical record writing,content completeness and finishing betimes.Methods Basic Norm of Medical Record Writing has been taken as norm standard requirement of medical record quality management.Reminding,modifying and finishing situation of medical record writing are been intelligent touch reminded and examined,from outpatient exam,treatment and hospitalization and medical record filing.Results Medical quality management system,based on electronic medical record,breaks application range of quality control,monitor and evaluation from traditional handwork to medical behavior and medical record quality.Putting informationization technology into highly real-time medical quality management activities improves comprehensively work efficiency and medical quality and gets quite good application effect.Conclusions To build a perfect medical quality management system provide effective management ways for electronic medical record monitor and management,making medical quality management work becoming more convenient and perfect.