病历内涵质量核查管理系统设计及实现

目的:进一步提高医院对于病历质量尤其是病历内涵质量的管理水平。方法:以医院信息系统(hospital information system,HIS)的Oracle后台数据库为基础,以Power Builder9.0为前台开发工具开发病历质量核查管理系统。结果:该系统已被成功应用到医院病历质量管理工作当中,并取得了良好的效果。结论:系统为临床医生和病历质量管理部门之间提供了良好的信息沟通平台,提高了医院病历质量管理的整体水平。     

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.     

Total medical record: an automated medical information system

The strength of the TMR system lies in its integration of medical and business information in a practical, easy-to-use design. It eliminates the delay, inefficiency, and bulk found in other medical information systems.     

A customized quality management implementation strategy

Austria's hospitals are not yet convinced total quality management (TQM) is a general cure for their problems. Neither competitive forces and cost consciousness nor regulations are pushing hospitals toward application of TQM methods. The Steierm?rkische Krankenanstaltengesellschaft, a multihospital corporation, used a bottom-up approach to implementation of TQM as a way of dealing with the lack of a strong quality assurance tradition.     

病案管理质量控制系统的实施

在病案管理工作中建立了环节质量控制系统。将病案统计室的工作按先后顺序分为入院登记、病案整理、编目、统计分析、计算机录入、入库和供应７个工作环节，制定出各项工作操作规范及岗位责任制，将每个工作环节作为一个质量单位，每个岗位的工作人员在完成本职工作的同时负责检查、监督前一个环节的工作，由此形成了质量控制网；按各级检查程序分为基础环节、中间环节、主体环节等３个管理环节，组成了环节管理系统。这个管理系统的特点是：以岗位责任制为主导，加强了各项规章制度的落实；在质量第一的前提下，以基础环节的质量管理为重点，注重病案从整理到入库全过程的质量控制；所有工作人员人人参与，各尽其责，使质量控制措施得以落实。经过初步实践，做到了病案２４小时回收率为９６％，保证了病案在病人出院后６天能够正常借阅，进入短时、高效的工作状态。     

The pursuit of excellence in medical record reviews

The ongoing medical record review program at Sioux Valley Hospital USD Medical Center needed reenergizing: the results weren't taken seriously or producing the needed improvements. Using tools from the Joint Commission, an HIM professional and a performance improvement coordinator redesigned the process, making it more efficient and more effective. Here's how they did it.     

PDCA循环在病历质量管理中的应用实例研究

摘要:目的　通过实施一系列的干预措施,全面改进我院病历质量,提高医生病历书写水平,并推广相应成功经验。方法　运用PDCA管理基本理论,结合5W1H分析法、QC七大手法、流程图等管理工具,对病历质量存在的问题、影响因素、干预措施及效果评估等进行全方位剖析,将病历质量数据做统计分析。结果　实施干预措施后我院病历质量得到明显改善,甲级病案率、平均分呈上升趋势,P＜0.0001,差异有统计学意义。结论　PDCA循环的应用对病历质量的提高有明显的推动作用,医院逐步形成了制度完善、标准规范、监控多元的病历质控体系,病历质量持续改进效果明显。     

浅析电子病案质量管理

电子病案质量是医院信息化管理工作的重要组成部分。本文阐述我院电子病案质量管理存在的问题,提出完善电子病案质量管理的对策。     

病历缺陷档案在病案质量管理中的应用

目的探讨病历缺陷档案在病案质量管理中的应用效果,为其他医院更好地进行病案质控提供借鉴。方法自2012年起,我院利用Excel2007,并根据《广东省病历书写与管理规范》中的住院病历评分标准为每位管床医生建立病历缺陷档案,对于每次抽查到的病历缺陷项目对应相应科室医生分别进行录入,同时将缺陷项目及时反馈主管医生本人,及时整改,对于屡次出现,且不改正的医生给予院级公示,并进行相应扣罚。实施1年后,对比前后全院病历质量改进情况。结果在为每位管床医生建立病历缺陷档案1年后,2012年全院甲级病案率达97．75％,高于2011年,差别具有统计学意义（P〈0．05）。特别是在地址填写不详、首页空项、漏诊／鉴别诊断混乱、既往／现病史描述不准确、病程记录无内涵、缺必要辅助检查及抗菌药物使用无指征等项目方面缺陷率较之前均有不同程度降低（P〈0．05）,且缺陷率随着时间的延长呈现逐步下降趋势（P〈0．05）。结论为临床医生建立病历缺陷档案可以及时监控全院各临床医生病历缺陷情况,及时反馈,及时整改,并对改进科室病历质量具有显著效果。     

Total quality management: lessons learned from the medical practice environment

Experience in dealing with the application of total quality management (TQM) to the medical practice environment suggests some generic lessons that can be helpful in applying TQM in other health care settings. These lessons focus on the need to address the motivation for TQM and its potential value; understanding the barriers created by the organizational and industry culture; identifying the structural barriers within the organization; clearly stating the guiding principles of the TQM effort; implementing the correct management tools for implementation; and allowing users of TQM to create new ideas for the application of TQM in their organizations.     

Using the Deming quality improvement method to manage medical record department product lines

The above application of the quality improvement cycle provides insight into the use of the Deming method to address one of several identified customer needs and expectations obtained during the managing phase of product-line administration. Implementation of the quality improvement method requires a major commitment from all team members. Process improvement requires a willingness to be detail oriented. Gathering of statistics--such as analysis turn-around time--and evaluation are critical. This objective view of processes requires accountability and a commitment to change. Improvements focus on long-term problem resolution, not the quick fixes that result from addressing symptoms of problems. True problem resolution occurs by solving the root causes of variations. Medical record departments must move from being outcome oriented to being process focused. It is no longer feasible to be constantly putting out fires in an environment that demands well-planned and well-designed products that meet customers' expectations. The long-term management of product lines requires a systematic method of planning, doing, checking, and acting. The Deming quality improvement method provides a framework for positive change that focuses on quality processes resulting in a quality product that meets consumers' needs.     

Product-line administration: a framework for redefining medical record department services

Product-line administration is a viable approach for managing medical records services in an environment that demands high quantity and quality service levels. Product-line administration directs medical record department team members to look outside of the department and seek input from the customers it is intended to serve. The feedback received may be alarming at first, as the current state of products usually reveals a true lack of customer input. As the planning, defining, managing, and marketing phases are implemented, the road will not be easy and rewards will be slow to come. Product-line administration does not provide quick fixes, but it does provide long-term problem resolution as products are refined and new products developed to meet customer needs and expectations. In addition to better meeting the needs of the department's external customers, the department's internal customers' needs and expectations will be addressed. The participative management approach will help nurture each team member's creativity. The team members will have the opportunity to reach their full potential while reaping the rewards and benefits of providing products and services that meet the needs and expectations of all department customers. The future of the health care industry promises more changes as the country moves toward some form of prospective payment in the ambulatory setting. Reactive management and the constant struggle to catch up can no longer be accepted as a management approach. It is imperative that the medical record department be viewed as a business with product lines composed of quality products. The planning, defining, managing, and marketing components of product-line administration afford responsiveness to the current situation and the development of quality products that will ensure that medical record departments are prepared for the future.     

Negotiating time scripts during implementation of an electronic medical record

Practitioners renegotiated time use requirements in an electronic medical record (EMR), thereby improving fit between health information technology (HIT) and clinical practices. The study contains important implications for managing HIT implementation.