从关键环节入手保证病案信息质量

病案是有关病人健康情况记录的资料,影响病案信息质量的关键环节有：病案基本信息采集、各项检验数据的生成、手术及治疗信息的记录、诊断及手术数据的编码、统计核查与数据提交等工作环节。造成病案信息质量偏差的主要因素有：医院HIS系统的可利用性及界面友好程度、HIS系统与病案管理系统的有效衔接、各工作环节人员的责任心与职业素质等。从关键环节入手保证病案信息质量主要有以下措施：全方位的业务培训、职业操守教育、建立有效的即时纠错提示及责任倒查体系、建立并完善有效的责、权、利相结合的管理体制,确保病案信息质量。

To Ensure Information Quality of Medical Records Starting with the Key Segments

Medical record is a documental material about patients’ health condition.The key segments of affecting medical records information quality include basic information collection of medical records,the formation of examination data,the formation of surgery and treatment information,the generation of diagnosis and ICD data of surgery and statistical evaluation and data submission and etc.The main factors causing quality deviation of medical records information include the availability and the degree of friendly interface of hospital HIS system,the effective connection between HIS system and medical records management system and responsibility and professional quality of staffs in every work segment.The countermeasures of ensuring medical records information quality starting from key segments are the omnibearing professional training,education of professional discretion in conduct,construction of effective instant error correction and responsibility track system and perfect,effective management system combing with responsibility,authority and benefit for ensuring the quality of medical records information.