新型冠状病毒肺炎疫情下病历质量管理应急策略

Emergency management strategy for medical record quality management during the outbreak of coronavirus disease 2019

病历在医疗、预防、教学、科研和医院管理等方面有着重要的作用。本次新型冠状病毒肺炎疫情非常严重,临床医师如何在新型冠状病毒肺炎防控与诊治的高强度、高压力环境下高质量、高效率地完成病历书写是医疗质量控制管理部门急待思考的重要问题。四川大学华西医院采取多种措施持续优化病历质量管理,对发热门诊、隔离病房的病历相关记录进行优化,在电子病历信息系统的支撑下采用多种形式进行病历质量管理,提高新型冠状病毒肺炎诊断治疗期间医务人员病历书写质量与效率。

Medical records play an important role in medical treatment, prevention, teaching, scientific research and hospital management. The epidemic situation of coronavirus disease 2019 is very serious. How to complete the writing of medical records with high quality and high efficiency under the high-intensity, high-pressure environment of the prevention, diagnosis, and treatment of coronavirus disease 2019 is an important issue for medical quality control management departments. West China Hospital of Sichuan University has adopted various measures to continuously improve the quality management of medical records, including optimizing the medical records of fever clinics and isolation wards, and using various methods of medical record quality management under the support of electronic medical record information systems, so as to improve the writing quality and efficiency of medical records during the diagnosis and treatment of coronavirus disease 2019.