基于自然公式配置的实时质控系统的设计与实现

Design and Implementation of the Real-time Quality Control System Based on the Natural Formula Configuration

目的:按照病历书写规范,督促医生规范的书写病历。方法:在触犯质控规则前两个小时,系统会提醒医生及时书写病历;如果超过质控时限医生仍未完成病历,系统会自动将病人病历锁定,需等待医务部审核通过后医生才能继续给病人书写文书;最后医务部会统计所有触犯质控项的医生,进行管理和考核。结果:"事前提醒、实时质控、事后分析"相结合的文书质控功能有效地约束了医生不规范书写病历的行为。结论:病历书写质量的监管,一直是医疗质量与安全管理中的一项重点工作,高效的文书质控功能,有效地督促了医生按照病历书写规范,保质保量的完成病历。

Objective： To urge the doctors to write medical records normatively, according to the standards of medical records writing. Methods： The system will remind doctors to write medical records by sending messages, two hours before the deadline of quality control rules. If the doctors still couldn＇t complete the records beyond the deadline, the system will lock the information of the patient automatically, and the doctors couldn＇t write records for the patient anymore until the manager examining past. At last, the manager will count all the quality control items in order to manage and access the doctors. Results： A quality control function, which occurs in real time with reminding beforehand, controlling in real time and analyzing afterwards, restricts the irregular behavior of writing medical records efficiently. Conclusion： To supervise the quality of medical records has always being an important work in management of medical quality and safety. The effective quality control function promotes the doctors to complete medical records with high quality efficiently, according to the standard of medical recording writing.