基于在线质控引擎的电子病历系统

在医疗信息化发展过程中,以电子病历为中心的临床诊疗信息化成为数字化医院建设的重点。电子病历在将病历书写电子化和结构化处理的同时,更需要与病历质量控制功能结合。现有的电子病历实现的病历书写和质控管理大多还局限在原有三级质控机制上,存在一定的滞后性和误差遗留问题。因此,探讨了在电子病历系统中如何将病历书写和质控管理更好地衔接和融合,从而使质控管理参与到病历文档产生的全生命周期,提高电子病历系统的准确性、及时性,保证规范化电子病历文档数据进入,为后期临床病历数据的科研分析奠定良好的数据基础,真正提高电子病历使用价值。

Electronic medical record based on online quality control engine

In the course of medical informationization development,the clinical diagnosis and treatment informationization centering on electronic medical record becomes the key point of construction of digital hospitals.The electronic medical record also need more combining with medical records function while digitizing and structuring the case record;however, the case record and quality control management realized by current electronic medical record are mostly confined to the original third quality control mechanis...