改进病案管理流程有效提高病案质量  

Improve the Medical Record Management Process and the Quality of Medical Records

作　　者：陈贤展[1] 彭传薇[1] 刘琛玺[1] 李富强[1] 

机构地区：[1]广州军区广州总医院

出　　处：《中国数字医学》2014年第12期95-96,101,共3页China Digital Medicine

摘　　要：目的:利用信息技术手段持续改进医院病案质量管理的流程,形成高效的质量控制闭环式管理。方法:通过质量控制系统改进已往质量控制流程,整合到HIS系统实时质控,从病历到病案的形成全程质控,落实控制目标及完善的评分体系。结果:医院以往病案首页填写错误率达到47%,改进流程后错误率降至5%以下。经过闭环式的质控管理流程持续改进,病案质量有明显的提升,病案的价值也得到有效体现。Objective：To use information technology to continuously improve the medical record quality management process of our hospital,and form the effective closed loop management of quality control.Methods：Through the quality control system,the previous quality control process is improved and integrated into HIS system for real-time quality control.From medical records to case history,the whole-course quality control is formed,and the control target and perfect scoring system are implemented.Results：In the past the error rate of medical records in hospitals was 47％.After improvement of the process,the error rate is below 5％.After the continuous improvement of closed-loop quality management process,the quality of medical records has been obviously improved,and the value of the medical records has also been shown effectively.

关 键 词：病案质量管理 流程改进 环节质控 错误率 

分 类 号：R319[医药卫生—基础医学]