病案质量简报的内容设计  

Content Design of Medical Record Quality Briefing

作　　者：苏静[1] 陈冬连[1] 洪雅君[1] 朱艳艳[1] 

机构地区：[1]中国人民解放军第174医院信息科,厦门市361003

出　　处：《中国病案》2016年第5期15-17,共3页Chinese Medical Record

摘　　要：一份高质量的病案质量简报不仅能够反映出一个医疗机构的诊疗水平、管理水平,也体现出病案室工作人员认真的工作态度。本文就某院病案室结合实际工作需求,设计完成《病案质量简报》的基本框架及内容。医院病案室采用统计图表加文字分析的形式设计《病案质量简报》,内容主要包括医院收治情况、病案编目情况、病案质控情况、病案流通情况等四大部分的图表信息,以及穿插其间的各类报表分析、工作情况、问题通报、经验教训等。其主要目的是实现对病案内容进行更深层次的挖掘后,以最直观、最易被接受的方式呈现在医院各级工作人员面前,并提出可靠的建议以供参考,使病案的作用得到最大的发挥。A high quality of medical record quality presentation can not only reflects the level of diagnosis and treatment of medical institutions, it is essentially a hospital daily operation of the data in the process of enrichment,reflects the hospital actual working condition of each work link. In medical record quality described in this presentation in the form of statistical charts ＋ text analysis, mainly including hospitals, medical record catalog,medical record quality control situation, medical circulation and so on four most chart information, as well as weaving through all kinds of reports and analysis, informed, medical record work stage summary and so on. The main purpose is to realize deeper research on the content of medical records, present them to the work staff of each grade of the hospital in the most intuitive and accepted way, and also put forward reliable advices for reference, thus to give full play to the function of medical records.

关 键 词：病案质量简报 临床服务 病案管理 

分 类 号：R197.323[医药卫生—卫生事业管理]