电子病案使用后取消终末质控的可行性探讨  

The feasibility of abolishing final quality control after the application of electronic medical record

作　　者：刘梦春[1] 刘飞[1] 

机构地区：[1]湖南省长沙市中南大学湘雅三医院

出　　处：《中国病案》2012年第8期22-23,共2页Chinese Medical Record

摘　　要：传统病案质控办法是采用住院期间的环节质控和出院后的终末质控,终末质控一直受到争议。纸质病案阶段,由于各种实际条件的限制,取消终末质控难以实现。使用电子病案后,对质控提出了新的要求,也给质控带来很大的便利。通过加强环节质控,即使取消终末质控,也能提供完整、达标的病案资料。更重要的是取消终末质控可增强互信,改善医患关系,有利于和谐社会的构建。The quality control of medical record is an important component of hospital management. Traditional quality control includes two meth- ods, one is segment quality control during hospitalization, and the other is final quality control after discharge. Moreover, final quality control has been controversial. During the period of using paper medical records, it is impossible to abolish final quality control because of many real difficulties. After the application of electronic medical record, it brings forward new demands to the quality control, and brings great convenience at the same time. We believe that excellent medical records also would be provided by strengthening the segment quality control even if the abolition of final quality control. Moreover,it can enhance mutual trust and improve the relationship of physician - patient, which is conducive to build a harmonious society.

关 键 词：电子病案 终末质控 环节质控 

分 类 号：R197.3[医药卫生—卫生事业管理]