信息化条件下病历质量监管流程改进  

Improvement of Medical Records Quality Control Processes under the Condition of Informatization

作　　者：张彦[1] 阳红[1] 陈兵[1] 林敏[1] 曹玲[1] 

机构地区：[1]成都军区昆明总医院,云南昆明650032

出　　处：《中国卫生质量管理》2016年第6期10-12,共3页Chinese Health Quality Management

摘　　要：应用病历质量管理软件,结合国家及军队相关规范标准,对病历质量进行自动核查、预警与管理,形成了病历质量自动化管控系统,在全年满负荷运转的情况下,病历合格率达到99.03%。通过信息化实现了病历质量全程管理、全员管理、科学分析、追踪改进以及数据化、精细化、量化、标准化的目标。Applying the medical records quality management software, with the standards of country and army, the automa- ted quality control system on medical records was established on the automatic verification, early warning and management of the quality of medical records, which achieved the improvement of quality control processes of medical records in clinical departments and hospital. In situations of annual running at full capacity, the passing rate of the medical records reached 99.03%. Through information technology, the goals were achieved, which included the full processes quality management of medical records, staff management, scientific analysis, tracking improvement and digitization, meticulous management, quantification, and standardization goals.

关 键 词：病历质量 流程 监控 管理 

分 类 号：R197.323[医药卫生—卫生事业管理]