病案数字化翻拍技术的质量控制研究

Research on the Quality Control of Medical Record Digitization Copying Technology

目的分析病案数字化翻拍技术的质量控制措施。方法采用随机数字表法选取我院2015年3月-2016年4月的病案100份,对病案进行全程质量控制,提高翻拍员的病案监控意识,严格按照相应的数字化翻拍流程进行操作,完善病案数字化质量管理网络,对干预前后数字化病案的质量变化进行观察和分析。结果经过人为干预、系统干预后,质检图像的合格率与干预前相比,差异具有统计学意义（P〈0.05）。结论加强对病案数字化翻拍的质量控制能够有效提高数字化病案的质量,确保病案的翻拍效果,降低对病案元件的依赖性,减少图像模糊等问题,为临床医疗工作提供了便利。

Objective To analyze the quality control measures for the digital medical record copying technology. Methods 100 medical records from March 2015 to April 2016 were selected from our hospital with the random number table. The quality control over the medical records was conducted throughout the whole process,the medical record monitoring consciousness of the copying staff was improved,operation was performed in strict accordance with the corresponding digital copying process,the digital medical record quality management network was perfected,and the quality changes of the digital medial records before and after intervention were observed and analyzed. Results The difference in the qualified rate of the quality control images after human intervention and system intervention was of statistical significance compared with that before intervention（P〈0.05）. Conclusion Strengthening the quality control over digital medical record copying can effectively improve the quality of the digital medical records,guarantee the copying effects of the medical records,decrease the dependency on medical record element,reduce problems like image blurring,and provide convenience for clinical medical work.