病案翻拍制作过程的质量管理  

Quality Control in Copying Photography of Medical Records

作　　者：柳剑[1] 魏敬[1] 董新昱[1] 张旭[1] 潘锐锐[1] 

机构地区：[1]南京医科大学附属南京第一医院,南京市210006

出　　处：《中国病案》2012年第3期10-11,共2页Chinese Medical Record

摘　　要：目的探索病案翻拍制作过程的质量管理方法,评价全程质量管理对数字化病案质量的影响。方法对病案翻拍数字化病案制作过程进行全程质量管理,包括建立数字化病案工程领导小组、建立新病案管理模式、规范病案翻拍数字化病案制作流程、培训工作人员、建立质检工作站、建立三级(翻拍人员、公司方、院方)质检反馈机制、建立病案领取、归还制度。评价比较进行全程质量管理前后数字化病案的质量变化。结果实施全程质量管理后总的质检合格率由94.7%提高到99.0%,P<0.01。结论实施全程质量管理可大大提高数字化病案质量,确保数字化病案的完整、准确、清晰,可最大限度地代表原始病案。Objective to investigate quality control methods in copying photography of medical records and to analyze influence of whole course qual- ity control on digitalization medical records. Methods It applies whole course quahty control during copying photography of medical records which in- cludes estabhshment of a leading team of digitalization medical records project; establishment of new model of medical records management; standardiza- tion about process procedure of copying photography; training staffs; quality inspection stations setting up; creating a three-stage quality inspection- feedback mechanism （photographing people, the company and the hospital） and establishment of borrow-return system of medical records. It evaluates and compares change of digitalization medical records quality before and after whole course quality management. Results After applying whale course quality control, total qualification rate increased from 94.7% to 99.9%, P 〈 0.01. Conclusion Applying whole course quality control can greatly im- prove the quality of digitalization medical records, for guaranteeing integrity, accuracy and clarity of digitalization medical records which may maximally reflect the original medical records.

关 键 词：过程质控 病案翻拍 数字化 质量管理 

分 类 号：R197.3[医药卫生—卫生事业管理]