谈2011版三级综合医院评审标准的病案信息利用

2011版三级综合医院评审标准中涉及与病案信息利用有关的描述,七章中有378条636款、核心指标48项,与病案信息相关,涉及全部章节有103条,占27.25％;涉及核心条款22项,占45.83％,第七章日常统计学评价几乎占有全部的内容.不少于150余个环节在实施评审中需要利用病案辅助完成,在评审中显示出病案发挥的作用.医院评审标准中还提示,在医院发展中重视病历书写质量的同时,应关注病案信息管理的学术、学科建设和持续改进,促进病案信息的充分利用.

Medical Record Information Use of The 2011 Version of Level 3 General Hospital Accreditation Standards

There are 378 items 636 terms and 48 core indexes in seven chapters related to medical record information use in 2011 version of level 3 general hospital accreditation standards. There are 103 items associated with medical record information refer to all chapters accounting for 27. 25%; 22 items refer to core terms, accounting for 45.83%. Daily statistical evaluation accounts for almost all the content in chapter 7. Not less than 150 links need to use medical record assisted in the accreditation, shows the role of medical record in the accreditation. It is suggested in the hospital evaluation standard, we should focus on academic, disciplinary construction of medical record information management in the development of hospital attaches great importance to the quality of medical record writing at the same time, promote the full use of medical record information.