电子化临床路径管理系统在病历内涵质量控制中的作用  

The Effect of Electronic Clinical Pathway Management System in Quality Control of Medical Records

作　　者：田伟[1] 窦忠东[1] 张光征[1] 万克林[1] 

机构地区：[1]临沂市沂水中心医院,临沂市276400

出　　处：《中国病案》2012年第1期31-32,共2页Chinese Medical Record

摘　　要：目的探讨电子化临床路径管理系统对病历的内涵质量控制的影响。方法总结、分析本院嵌入电子病历系统而开发的电子化临床路径管理系统的特点、优势和效果。结果电子化临床路径管理系统对变异的追踪、分析、讨论、记录,成为临床医师书写病历的重要参照,引导他们提高病历的内涵质量。结论电子化临床路径管理系统在质控病历内涵质量方面具有独特优势,能够提高病历内涵质量。Objectives This paper discusses the control effect of electronic clinical pathway management system to connotation quality of medical records.Methods It summarizes and analyzes the characteristic,advantages and effect of electronic clinical pathway management system designed by our hospital inserting into electronic medical records system.Results The tracing,analysis,discussion and record of variation from electronic clinical pathway management system have become the important reference of medical records writing to clinical physicians,which guides them to improve connotation quality of medical records.Conclusions Electronic clinical pathway management system has its unique advantages in connotation quality of medical records quality control that can improve connation quality of medical records.

关 键 词：临床路径管理 内涵质量 电子病历 

分 类 号：R197.324[医药卫生—卫生事业管理]