建立专家评审制度提高电子病历内涵质量的实践

Practice on Establishing Expert Evaluating System to Enhance the Connotative Quality of Electronic Medical Records

目的针对目前电子病历内涵质控面临的问题,探讨提高电子病历内涵质量的实践和效果。方法借助信息化评审平台,组建病历评审专家组,建立电子病历内涵质量评审机制。结果通过一年的具体实践,在术前讨论记录、手术记录、首次病程记录、上级医师查房记录、出院记录的内涵质量均得到全面提升。结论利用专家评审病历内涵质量的形式,对提高病历内涵质量起到积极作用。

Objective To probe into the practice and effect on enhancing the connotative quality of electronic medical records aiming at the difficulty of connotative quality control of electronic medical records.Methods Using informationazition platform and expert evaluating system,the evaluating system of connotative quality was established effectively.Results Through one-year practice,the connotative quality was upgraded comprehensively on preoperative discussion,surgical records,first course records,superior physician patient rounds records and discharge records.Conclusion By establishing expert evaluating system,the connotative quality could be enhanced effectively.