| 基于CDR的临床路径终末病案质控 |
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| 引用本文： | 刘叶珍,吴智娟,李开祥.基于CDR的临床路径终末病案质控[J].中国病案,2012(12):19-21. |
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| 作者姓名： | 刘叶珍 吴智娟 李开祥 |
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| 作者单位： | 深圳市宝安区妇幼保健院;深圳市宝安区西乡人民医院 |
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| 摘 要： | CDR是以病人为中心重新构建的新的一层数据存储结构，含有病人全部的信息。基于CDR的临床路径质控管理系统根据质控人员选择的临床路径自动筛选出病历，质控人员检查CDR同时在系统里记录病案存在的问题，最终形成质控报表。基于CDR的临床路径终末病历质量监控系统提供了一个适宜于纸质病案数子化与电子病历的统一的临床路径终末病案质控模式，可优化工作流程，提高工作效率与质量。
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| 关 键 词： | CDR 临床路经 病历质控 |
Terminal Medical Records Quality Control of Clinical Pathway Based on CDR |
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| Liu Yezhen,Wu Zhijuan,Baoan Maternity and Child Health Care Hospital,Shenzhen,Guangdong Province,China,Li Kaixiang.Terminal Medical Records Quality Control of Clinical Pathway Based on CDR[J].Chinese Medical Record,2012(12):19-21. |
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| Authors: | Liu Yezhen Wu Zhijuan Baoan Maternity and Child Health Care Hospital Shenzhen Guangdong Province China Li Kaixiang |
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| Institution: | ,Xixiang People’s Hospital,Shenzhen 518133,Guangdong Province,China |
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| Abstract: | CDR is a new data storage structure of patient-centered, contains all of the information. Based on the CDR clinical path quality control management system can screen out medical records according to the clinical path which quality control personnel choose. Quality control personnel inspection CDR and record the existing problems in the medical record at the same time. Finally form quality control report forms. Based on the CDR clinical path quality control management system provides a clinical pathway terminal medical record quality＇control mode which is suitable for the unity of the paper medical record digitized and electronic medical records. It can optimize work flow, improve the work efficiency and quality. |
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| Keywords: | CDR Clinical pathway Medical records quality control |
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