The system analysis as a tool for medical record department improvements

Selecting opportunities for process improvements in the health information management department can be achieved through a formal system analysis. This article covers the step-by-step examination of one department's quality improvement efforts.     

构建医疗服务价格评价指标体系的研究

目的设计与制订医疗服务价格评价指标,构建一套对医疗服务价格的制订、执行结果进行完整评价的指标体系,为政府部门提供医疗服务价格管理和决策工具。方法运用了医学、经济学、统计学、价格学和循证医学的理论与方法,通过德尔菲(Delphi)法,建立评价模型设计和制订医疗服务价格评价指标体系。结果本研究建立的医疗服务价格评价指标体系能够基本反映在医疗服务价格形成和执行过程中,对政府的管理目标、医院的医疗服务质量、工作效率、成本控制、经济效益和居民的参与及满意度进行测评。结论建立健全一套医疗服务价格评价指标体系势在必行,此研究建立的评价指标体系基本能够满足现阶段医疗服务价格评估的需要。     

Risk management: role of the medical record department

Good record-keeping practices contribute to the high quality of the medical record. Is the medical staff actually aware of the multiple uses of the medical record today as opposed to only a few years ago? This is all in keeping with multiple requirements for accreditation, state licensing requirements, hospital medical staff rules and regulations, and a more aggressive consumer. Physicians and attorneys alike depend on the documentation in the medical record to support their case. An independent detailed recollection of the case by caregivers without use of the medical record would be extremely difficult. Nothing can take the place of an accurate account of the patient's care in the medical record. Defense in the absence of supporting documentation would be very weak, if not lost. It is clear that inadequate or incomplete medical records expose the physician and the hospital to risk. Hospital rules and regulations should be strictly enforced to enhance patient care and to avoid potential legal action. If documentation problems are identified, utilize the medical staff committees for recommendations and action. Medical records are an integral part of patient care responsibility and should be treated as such. The medical record is a legal document that is the most reliable record of care rendered to the patient. In legal settings, the record will be scrutinized by expert witnesses for the plaintiff and the defense. What the records do not contain may be as important as what they do contain when there is an allegation that the patient's condition warranted intervention or action that was not taken.     

An integrated clinical computer system: implications for a medical information services department

The hybrid record--both paper and electronic--is a cumbersome byproduct of the evolution to the computer-based patient record. Nancy Walker describes how William Beaumont Hospital managed its information services with this mixed media record. Her article provides practical solutions for health information managers including downtime procedures, report distribution plans, release of information steps, and audit procedures for maintaining confidentiality.     

Total quality management: an implementation strategy for excellence in the medical record department

Trustees do not seem to agree on how quality accountability will be accomplished, but they are starting to agree that procedures to establish quality accountability are necessary. They also agree that leadership from the board level, coupled with a firm resolve to monitor quality, will ensure that hospitals provide high-quality care and services to their most important and influential customers: patients. The manufacturing industry has provided the health care industry with the benefit of its experiences with continuous quality improvement, including the pitfalls. It is both exciting and challenging to learn the philosophies of total quality management and build a customized strategy for excellence, especially in medical record departments. As a customer of numerous processes throughout the health care organization and a supplier of products and services as well, the MRD represents a common thread throughout the organization, often linking people and departments together. A medical record professional who is working in a health care organization whose executives believe in TQM can expect great things in the decade ahead.     

面向精准医疗服务的信息标准体系框架构建

借助远程/移动医疗平台建设精准医疗信息系统,面向基层患者开展多级协同的精准医疗服务是精准医疗的重要目标。目前国内外针对精准医疗服务的信息标准、规范体系尚未建立。文章通过分析精准医疗信息标准体系框架建设的必要性和建设原则,提出精准医疗信息标准体系框架,并就标准制定与应用提出建议,以期为我国精准医疗信息标准建设提供参考借鉴。