实时监控电子病案强化质量管理  

Monitoring the Medical Record Quality on Real time

作　　者：王磊 李志韧 袁默 梁歌 刘建斌 

机构地区：[1]北京市解放军第二炮兵总医院医务部

出　　处：《中国病案》2005年第1期30-31,共2页Chinese Medical Record

摘　　要：目的加强病案质量管理。采用分时段实时监控方法,及时发现电子病案存在的缺陷,采取考评信息反馈,促进电子病案质量的提高。方法通过医院病人信息查询系统,对全院电子病案质量进行实时监控分析,了解首次病程记录、入院病历、三级检诊完成时限。结果电子病案大多存在不良拷贝、书写、打印不及时、上级医师审签时限滞后等问题。结论通过电子病案质量实时控制,可以加强病案质量环节管理,强化依法行医质量意识,为终末病案质量提高奠定基础。Objective Using RealTime Controlling management to monitor the defaults in the electronic medical records timely, in order to enforce the quality management of the medical records. Methods Monitoring and analyzing the quality of the electronic medical records through the realtime controlling system to know the first disease process, the admission record and time limit of examinations and diagnosis. Results In the medical records, there are many defaults, including bad copy, delayed writing, printing, and the sign by the upper doctors. Conclusion By the realtime controlling we want to enforce the quality management of the medical records on the net, raise the sense of quality, finally, to improve the quality of the medical records.

关 键 词：电子病案 病案质量管理 依法行医 病人信息 入院 首次 医师 质量意识 考评 滞后 

分 类 号：R197.324[医药卫生—卫生事业管理]