紧扣医疗过程关键节点的电子病历质量控制与管理

应用电子病历系统,利用临床信息源和信息共享,开发电子病历质量控制系统,紧扣医疗诊治过程中关键环节点,设置质控规则和质控节点的触发关联点,通过科室质控、院级质控、专项质控,多环节、多层次的在线质控,注重质控细节和“事先—事中—事后”提醒功能,充分发挥电子病历质控模式的工作效率高、标准统一、时效性强、涵盖质控节点广、可开发应用的特殊功能优势,取得较好效果.质控病历覆盖面及检查率明显提高,特别是运行病历环节质控力度得到大幅度加强,使病历书写中存在的缺陷和不足能及时发现、纠正,减少医疗隐患,保证医疗质量.

Electronic Medical Record Quality Control Closely Related to the Key Nodes of Medical Process

With the application of electronic medical record system,using clinical information source and information sharing,the electronic medical record quality control system is developed,which is closely related to the key nodes in the process of medical treatment.The rules of quality control and trigger connection points of quality control nodes are set.Through the department special quality control,the hospital-level quality control and the special quality control,the multi-link and multi-level online quality control is realized.The quality control details and ＂beforehand-concurrent-afterwards＂ remind functions are paid attention to.The special function advantage of high efficiency,unified standards,strong timeliness,wide quality control nodes,and development and application of the electronic medical record quality control are given full play to.Good effects are achieved.The coverage and check rate of quality control medical records are increased significantly.Especially the quality control in the link of the running of medical records is dramatically strengthened,so that defects and deficiencies in the writing of medical records can be timely discovered and corrected.The medical risks are reduced and the quality of medical treatment is ensured.