病案数字化翻拍技术的质量控制研究  

Study on Quality Control of Digital Copying Technology Records

作　　者：杨婷[1] 涂自良[1] 吴蔚[1] 方孝梅[1] 

机构地区：[1]十堰市太和医院,湖北医药学院卫生管理与卫生事业发展研究中心

出　　处：《中国数字医学》2014年第4期44-46,共3页China Digital Medicine

基　　金：湖北省十堰市太和医院软科学计划项目(编号:2013rkt28)~~

摘　　要：目的:探索病案数字化翻拍技术的质量控制措施,评价全程质量管理对翻拍病案质量的影响。方法:采取强化以病案管理人员为主导的全程质量控制模式、规范数字化翻拍流程、对翻拍员进行病案信息常识指导、建立质量检查工作站、形成三级质检反馈制度等手段,建立一个纵横交错、严密有序的病案数字化质量管理网络。比较干预前后数字化病案的质量变化。结果:设置人为干预和系统干预后总的质检图像合格率由94.62%提高到98.59%,且有统计学差异(p<0.0001)。结论:全程质量控制程序,对提高数字化病案质量作用显著,有效保证翻拍病案质量,在实际应用中可最小程度依赖病案原件。Objective： Quality control measures to explore digital copying technology records, effect of whole process quality management evaluation on a remake of the quality of medical records. Methods： To strengthen the quality control mode to the medical record management as the dominant, specification of digital copying process, medical records information knowledge guidance to remake, the establishment of quality inspection start in, the formation of three quality inspection and Feedback system, establish a strict and orderly arranged in a crisscross pattern, the digital medical record quality management network. Results： Set up artificial intervention and after intervention quality inspection system image total qualified rate increased form 94.62% to 98.59%, and there were significant differences （ P〈0.0001 ） .Conclusion： The whole quality control program, significant to improve the quality of digital medical record, effectively guarantee there make of medical record quality, in the practical application of minimal dependence on the original medical records

关 键 词：病案数字化 病案翻拍 翻拍图像 质量控制 质量管理 

分 类 号：R197.1[医药卫生—卫生事业管理] R319[医药卫生—公共卫生与预防医学]