网上病历监控的体会  

The Experience of Monitoring and Controlling the Medical Records on Line

作　　者：王悦[1] 史仲初[1] 王于虹[1] 王翎[1] 

机构地区：[1]北京大学首钢医院医疗质量处

出　　处：《中国病案》2009年第5期41-42,共2页Chinese Medical Record

摘　　要：我院通过HIS系统在网上对病历完成时限、合理用药、合理检查、病情告知记录、病历书写存在的问题等五方面进行了实时监控,病案质量有了进一步提高。网上病历监控加强了监管部门与临床科室的沟通,保证了医保各项政策的执行,同时也保证了病案的终末质量,减少医疗纠纷。With the HIS system, we carry out a real- time monitoring on line in five aspects, including the time limit of completing the medical records, medication, examination, the notes to inform the client/family and documentation. Consequently, the quality of the medical records has been greatly improved. Online medical control have strengthened the communication between the supervision department and the clinical departments, ensured the implementation of health insurance policies, and guaranteed the quality of the medical record of the terminal and reduced medical disputes.

关 键 词：病历 监控 质量 

分 类 号：R197.3[医药卫生—卫生事业管理]