电子病历环节质量控制系统的功能设计与应用

目的利用信息系统对住院电子病历进行环节质量控制，提高质控管理工作的效率和精细化程度；通过质控系统进行医疗质量指标数据的统计与分析。方法将电子病历与医嘱、麻醉、检验、影像、超声等系统建立接口、实现数据共享，采集诊疗事件和时间节点，设计出针对环节和时限的质控模块、进行相关医疗质量指标数据的统计与分析。结果设计开发的质控系统具备六个质控工具；一个科内医生病历审核系统；危重症报告与评分等上报管理系统；能够对关注的医疗质量指标数据进行统计分析。结论住院电子病历环节质量控制系统的设计功能全面，符合卫生部《病历书写基本规范》与《电子病历基本规范》的要求，能够满足《三级综合医院评审标准（2011年版）》对病历质控管理的相关要求；利用质控工具能够实现病历的全面质控和重点质控。

Functional Design and Application of Electronic Medical Record Quality Control System

Objective To realize the procedure quality control of electronic medical record by information system, and to improve the efficiency and the refinity of quality control management. Statistics and analysis of medical treatment quality data can be obtained by the quality control system. Methods Data sharing by the connection of electronic medical records and sereral other system＇s, such as medical order, anesthesia, laboratory, image, and ultrasound. Collect the diagnosis and treatment affairs and time points, design the quality control models of the procedures and time points, and then make the statistics and analysis of the relative medical treatment quality data. Results The quality control system contains six instruments, a medical record examining system, and a report management system of critically illness reported and scored. It makes the statistic and analysis of the medical treatment quality data feasible. Conclusion The functional design of the electronic medical record quality control system is comprehensive. It accord with the standards of Ministry of Health ＂medical record writing basic norm＂ and ＂electronic medical record basic norm＂. It can satisfy with the requirements of medical record quality control management of ＂tertiary general hospital evaluation standard （2011 edition）＂. We can realize comprehen- sive medical quality control and key quality control by the quality control system.