病历质量管理信息系统的设计及应用  

Design and application of medical record quality management information system

作　　者：桂建军[1] 房镔楠 崔子竹 

机构地区：[1]解放军254医院急救康复中心,天津300020

出　　处：《医疗卫生装备》2015年第12期67-70,共4页Chinese Medical Equipment Journal

摘　　要：目的:解决人工核查病历质量工作耗时费力、覆盖率低、难以实现和加强内涵质量管控的问题。方法:由医院信息系统(1hospital ingormation system,HIS)、电子病历、实验室信息系统(laboratory information system,LIS)及影像归档和通信系统(picture archiving and communication system,PACS)等系统中自动抓取患者医疗数据,通过图形化的方式使数据精确组合后,高度集成地展现给质控医生,并提供多种辅助检测功能。结果:病历质量管理信息系统的实现大幅提高了病历质量的检测效率和检测覆盖率,使质控医生能够快速、准确地完成病历内涵质量问题的检测、定位与沟通反馈工作,医院病历质量整体水平得到提高。结论:通过信息化手段简化工作、提高病历内涵质量检测效率与管控能力,满足了医院对医疗质量更深层次的管理需要,适用于所有使用"军卫一号"系统和新版电子病历系统的医院。Objective To solve the problems of manual verification of medical record in time, coverage rate and quality management. Methods Patient medical data were extracted from HIS, medical record, LIS, PACS and etc, and then were combined accurately by graphical ways before being integrated and presented to the doctor. Multiple auxiliary detection functions were realized. Results The medical record quality management information system enhanced the efficiency and coverage rate of medical record quality detection, and enabled the doctor to deal with issues related to medical record quality. Conchuslon The system heightens the medical record management, and can be applied in the hospital with No.1 Military Medical Project System and new electronic medical record system. [Chinese Medical Equipment Journal, 2015,36（ 12 ） ： 67-70]

关 键 词：电子病历 内涵质量 信息化管理 

分 类 号：R197.323[医药卫生—卫生事业管理]