摘要
目的:探讨病历质量控制系统在病案首页质量监管中的作用。方法:通过对传统工作流程的改造,利用病历质量控制系统、医生工作站、病案编目系统、数据核查工具Check、图像工作站、检验系统、病理系统等作为一个整体联合起来,实现对病案首页全方位的智能监控与管理,及时发现病案首页填写缺陷,提出修改意见,实现高效的管理。结果:有效提高病案首页的填写质量,超过一半以上的科室实现"零差错",全院病案首页填写错误率控制在5%以下,首页填写质量大幅提升。
Objective: Discussing the effect of medical record quality control system in improving filling quality of the home page of medical record. Methods: By reforming traditional workflow and using medical record quality control system, doctor workstation, medical record classifying system, data Check tool, Photo workstation, lib-system and pathology system as an whole system, manage data quality of the home page of medical records comprehensively, find out mistakes timely, and give out suggestions, Result: The effect in improving data quality is significant. More than 50%'s clinical departments fill home pages without any mistakes and the whole mistake rate has reduced less than 5%.
出处
《中国数字医学》
2013年第12期85-86,97,共3页
China Digital Medicine
关键词
病案首页
质量控制系统
数据质量
流程改造
home page of medical record, quality control system, data quality, workflow reformation