我院对提高病历内涵质量的实践探索  

Practice of improving the connotative quality of medical records in our hospital

作　　者：卢瑶[1] 张健林[1] 蒋小花[1] Lu Yao;Zhang Jianlin;Jiang Xiaohua.(Liuzhou Workers Hospital, the Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou 545004, Guangxi Zhuang Autonomous Region, Chin)

机构地区：[1]广西医科大学第四附属医院柳州市工人医院,柳州545004

出　　处：《中国医疗管理科学》2018年第3期28-30,共3页Chinese Journal Of Medical Management Sciences

基　　金：基于六级标准电子病历系统的医疗质量管理体系改进与应用研究(编号Z20170931)

摘　　要：提升病历的内涵质量是各级医院管理者的重要议题。我院运用信息化质控系统锁定重点病历,以临床科室青年后备干部组建专家组,对病历的内涵质量进行点评,形成专题化的培训、整改活动,给病历审核带来了全新的管理视角,完成了从发现问题到解决问题的闭环管理。To improve the connotative quality of medical records is an important issue for hospital administrators at hospitals of all levels. Our hospital adopts a digital quality-control system in managing medical records, with an emphasis on key medical records. An expert panel, comprising outstanding young physicians, was set up to comment on the connotative quality of medical records. Specialized training and reform activities were carried out, which have brought about a new perspective of management in the review of medical records, thus forming a closed-loop problem searching and solving management system.

关 键 词：医院信息化 病历质量 闭环管理 

分 类 号：R197.323[医药卫生—卫生事业管理]