病案首页质量管理系统的设计与应用

Design and Application of Quality Management System in Medical Record Homepage

目的:病案首页是病案中包含病人住院信息最丰富的部分,是病案质量管理的重要内容,应该建立一个以"病案首页管理"为核心的系统,以提高病案首页质量。方法:通过分析病案首页管理的业务流程,设计出一套基于高内聚、低耦合设计原则的病案首页质量控制系统。结果:系统投入使用三年后,全院首页差错率由原来的38%下降至3%以内,有相当一部分科室实现"零差错"归档;出院病案"三日归档率"由原来的76%提升至96%以上。结论:病案首页质量管理系统解决传统的病案首页质量手工管理的问题,实现了病案首页精细化管理和评估。

Objective： Medical record homepage is rich in patient information and it is important in medical record management so that we should develop a system as the core of medical record homepage management to improve the quality of medical record homepage. Methods： After analyzing the work flow about medical record homepage, we designed a quality management system in medical homepage which was based on the designed principle of high cohesion and low coupling. Results： The error rate in medical record homepage have dropped from 38% to 3% even zero and the rate of medical record homepage filed within three days have been raised from 76% to 96% after using the system for three years. Conclusion： The medical record homepage management becomes automation instead of manual by the system, which realizes monitoring, management and assessing meticulously.