基于电子病历系统的门诊医疗质量管理

Outpatient Medical Quality Management Based on Electronic Medical Record System

门诊电子病历系统(EMRS)是以电子病历(EMR)为核心的医院信息系统(HIS)、医学图像档案管理与通讯系统(PACS)、检验信息系统(LIS)、合理用药等的集合。该系统为门诊医师提供高效便捷应用体验的同时,规范医师在患者身份识别、挂号、病历书写、医嘱录入、检验检查申请与结果引用、开具病假证明、复诊随访及入院床位预约等诊疗行为。多系统高度融合的门诊电子病历系统实现了门诊就诊流程各环节医疗质量管控由传统人工终末抽查升级为信息系统全程管控,门诊不合格病历比率由7.79%降至1.90%,门诊处方合格率由91.75%升至98.56%,门诊医师准点开诊率由58.20%升至96.01%。基于电子病历系统的门诊医疗质量全程闭环管理有效促进了门诊医疗质量、服务品质及管理效率的持续提升。

Outpatient electronic medical record system(EMRS)is a collection with the core of electronic medical record(EMR),hospital information system(HIS),medical image file management and communication system(PACS),inspection information system(LIS),rational medication and so on.The system provides outpatient doctors with an efficient and convenient application experience,while regulating doctors’patient identification,registration,medical record writing,medical order entry,inspection and examination applications and result quotation,issuing sick leave certificates,follow-up visits,and hospital bed appointments.The multi-system highly integrated outpatient electronic medical record system has realized the medical quality control of each link of the outpatient consultation process from traditional manual terminal spot check to the entire management and control of the information system.The unqualified medical record rate in the outpatient department has been reduced from 7.79%to 1.90%,the eligible rate of outpatient prescriptions increased from 91.75%to 98.56%,and the on-time consultation rate of outpatient doctors increased from 58.20%to 96.01%.The whole process closed-loop management of outpatient medical quality based on electronic medical record system has effectively promoted the continuous improvement of outpatient medical quality,service quality and management efficiency.