建立与完善电子病历质控体系的探讨  

Discussion on Establishing and Improving the Quality Control System of Electronic Medical Records

作　　者：孙慧子 董晓明[1] 沈丽娟 朱洪涛 SUN Hui-zi;DONG Xiao-ming;SHEN Li-juan;ZHU Hongtao(The Second Affiliated Hospital of Qiqihar Medical University,Qiqiha’er,Heilongjiang,161006,China)

机构地区：[1]齐齐哈尔医学院附属第二医院,黑龙江齐齐哈尔161006

出　　处：《中国医院管理》2018年第11期44-46,共3页Chinese Hospital Management

摘　　要：目的探讨建立与完善电子病历质控体系的方法,以实现电子病历质量的提高,为医疗质量提供更好的保障。方法通过研读《医疗质量安全核心制度要点》,分析电子病历质量现状及质控方法,找出电子病历质量存在的问题及解决途径。结果电子病历质量的提高不仅在于医生自身意识,也要合理界定分工及职责并开展多级质控。结论完善电子病历质控体系、提高电子病历质量需要医院各个部门的共同协作。Objective To explore the methods of establishing and improving the quality control system of electronic medical record,so as to improve the quality of electronic medical record and provide better guarantee for medical quality.Methods By studying the Key Points of the Core System of Medical Quality and Safety,analyzing the current quality situa?tion and quality control methods of electronic medical records,and finding out the existing problems and solutions of the quality of electronic medical records.Results The improvement of the quality of medical records lies not only in the con?sciousness of doctors themselves,but also in the rational division of labor and responsibilities and the development of multi-level quality control.Conclusion Improving the quality control system of medical records and improving the quality of medical records require the joint efforts of all departments in the hospital.

关 键 词：病历质量 病历质控 质控体系 

分 类 号：R197.323.1[医药卫生—卫生事业管理]