依托信息化手段实现有效的病历三级质控  

Achieve the Effective 3-level Quality Control of Medical Records By Information Technology

作　　者：胡敏[1] 茅建华[1] 李永昌[1] 于京杰[1] 

机构地区：[1]南京军区南京总医院

出　　处：《中国数字医学》2017年第12期108-109,共2页China Digital Medicine

摘　　要：目的:在医院电子病历的基础上,利用病历质量管理系统,协助病历三级质控制度更好的执行。方法:利用系统中的病历自动核查、数据集中展示、数据统计分析等功能,协助各级质控人员完成相应工作。结果:保证了病历三级质控的落实,减轻了相关人员工作量,提高工作效率。结论:依靠信息化系统,保证病历质量。Objective： On the basis of hospital electronic medical record, we use medical record quality management system to assist the implementation of the three level quality control system. Methods： Using the functions of automatic medical record verification, data centralized display and data statistics and analysis in the system, the quality control staff at all levels should be assisted to do the corresponding work. Results： It ensures the implementation of three levels of quality control and quality control of medical records, reduces the workload of related personnel and improves work efficiency. Conclusion： Relying on information system to ensure the quality of medical records in our hospital.

关 键 词：三级质控 电子病历 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]