利用病历质量控制系统对促进病案首页质量提高的探讨

Discussion on Effect of Medical Record Quality Control System in Improving Data Quality of the Home Page of Medical Record

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%.