中长期肿瘤患者院后随诊的持续改进  

Continuous Improvement of Follow-up after School for Medium and Long Term Cancer Patients

作　　者：樊美娜[1] 王凯鹏[1] 

机构地区：[1]中国医学科学院肿瘤医院病案室,北京市100021

出　　处：《中国病案》2015年第4期6-9,共4页Chinese Medical Record

基　　金：2014年"北京希望马拉松基金"联合攻关课题(NCC2014GG-09)

摘　　要：结合某肿瘤专科医院病案随诊工作的实际情况,中长期恶性肿瘤患者随诊工作围绕不同的随诊种类进行,还需要随诊检索及与HIS系统的数据接口的支持。随诊的难点在于工作量巨大、随诊患者基本信息不准确、专题随诊差异性大造成信息难以共享等。通过建立专职随诊机构、建立随诊信息管理系统、规范随诊信息项、临床医师参加随诊工作等措施保证随诊的科学性。实施随诊信息化管理后有效提高工作效率,降低中长期患者失随率。开展随诊工作应合理配备病案信息管理专业技术人员,充分发挥其专业特长,紧密与临床医师协作,沟通随诊需求及课题设计思路,以便随诊人员充分理解及掌握问卷核心思想,最大限度的提高随诊数据质量。follow-up work of medium and long-term malignant tumor patients need follow-up retrieval and data interface with the HIS system support combined with the actual situation of a tumor hospital. Difficulties of follow-up are big workload; basic information is not accurate, difficult to share information, etc. Through the establishment of full-time follow-up institutions, establishing follow-up information management system, standardized follow-up,clinical physicians participate in follow-up work to ensure the scientific nature of the follow-up. The implementation of Information management can effectively improve work efficiency and reduce the rate of loss, at the same time should have medical record information management professionals, give full play to their professional expertise,collaborate with clinicians, communicate needs and design thought, so that follow-up staffs can fully understand and grasp the questionnaire core idea, maximum limit to improve data quality.

关 键 词：中长期 肿瘤患者 院后随诊 持续改进 

分 类 号：R197.5[医药卫生—卫生事业管理]