病历质量管理系统设计实现

Design and Implementation of Medical Record Quality Management System

目的实现对全院环节病历及时、全面、高效的质量控制,提高整体病历质量管理水平。方法针对电子病历形式质量的自动化核查、预警与管理功能进行开发,最终形成一套全面、及时、有效的病历质量自动化管控系统。结果与结论建立病历质量独立审计与管理控制体系,依托信息系统实现质量管理核心制度的落实。

Objective To achieve the timely, comprehensive and effective quality control of the hospital medical records, and to improve the overall quality of medical records management. Methods The automatic verification, early warning and management function of the quality of the electronic medical record form were designed to develop a comprehensive, timely and effective quality control and management system for medical records. Resuits and Conclusion A system for separated audit of medical records quality and management control system was constructed, which achieved the implementation of core system of quality management.