医院环节病历质量自动化核查与管理系统设计  

Design of a System for Quality Automatic Verification and Management of Link Medical Record in the Hospital

作　　者：胡敏[1] 茅建华[1] 汪春晖[1] 于京杰[1] 

机构地区：[1]南京军区南京总医院信息科,江苏南京210002

出　　处：《中国医疗设备》2016年第2期112-114,72,共4页China Medical Devices

摘　　要：目的在医院现有电子病历的基础上,利用计算机技术构建独立的环节病历数据自动抓取、分析核查、问题预警等功能的质量管理系统,实现全面、高效的环节病历质量自动化管控。方法以百泰网络病历质量管理系统为基础,开发嵌入式环节病历质量检测和预警软件,用于本院的病历质量自动核查与管理。结果实现了全院环节病历质量的自动化筛查、实时监测预警与质量控制,简化了工作环节、大幅提高了质控工作效率。结论系统试运行后,试运行科室的归档病案甲级率提升明显。Objective Based on the current hospital electronic medical records, to construct a link medical quality management system that includes data acquirement, problem analysis and verification, and early warning by using computer technology, so as to realize a comprehensive and efficient form of quality control of link medical records. Methods On the basis of the BTECH network medical record quality management system, to develop the quality monitoring software for embedded link medical record form and the early warning software, which were used in the automatic quality verification and management of our medical records. Results The automatic quality verification of the link medical record was realized. The early warning and quality control system were also accomplished. We have realized the whole link quality of the hospitalized patients＇ medical records in network automatic census, real-time monitoring and early warning, and quality control. Conclusion The test run of the system significantly increased the rate of grade A in the piling of medical record documentation.

关 键 词：电子病历 环节病历 质量管理 医院信息系统 

分 类 号：TP311.52[自动化与计算机技术—计算机软件与理论]