基于住院电子病历修改的闭环管理实践  

Closed-loop Management Practice Based on Inpatient Electronic Medical Record Modification

作　　者：许书培 刘刚[1] 曾茜 徐建玲[1] 陈武朝[1] XU Shu-pei;LIU Gang;ZENG Qian;XU Jian-ling;CHEN Wu-chao(People's Hospital of Guangxi Zhuang Autonomous Region,Nanning,Guangxi Zhuang Autonomous Region,530021 China)

机构地区：[1]广西壮族自治区人民医院,广西南宁530021

出　　处：《中国卫生产业》2020年第22期78-80,共3页China Health Industry

基　　金：广西卫生计生委自筹经费科研课题(Z20180781);广西医疗卫生适宜技术开发与推广应用项目(S2017084);广西壮族自治区人民医院院内青年基金课题(QN2017-17);广西壮族自治区卫生和计划生育委会科研课题(Z20170374)。

摘　　要：目的运用闭环管理思维,设计住院病历修改的封闭回路,有效提高病历资料的质量和完整性。方法采用PDCA的方法,在病历修改的申请、审批、修改、监控、复核等环节形成有效的闭环回路。通过人工查验和医院电子病历系统痕迹查询的方式,促进闭环管理的高质量运行。结果形成高质量的住院病历修改闭环管理制度。结论通过在住院病历修改中运用闭环管理,可以有效提高病历修改的准确性,缩短修改时间,保障病历资料作为法律文书的权威性。Objective Use closed-loop management thinking to design a closed loop for inpatient medical record modification,and effectively improve the quality and integrity of medical records.Methods The PDCA method is used to form an effective closed loop in the application,approval,modification,monitoring,and review of medical records modification.Promote the high-quality operation of closed-loop management through manual inspection and trace query of the hospital electronic medical record system.Results A high-quality closed-loop management system for inpatient medical records modification was formed.Conclusion By using closed-loop management in the modification of hospitalized medical records,the accuracy of medical record modification can be effectively improved,the modification time can be shortened,and the authority of medical record data as a legal document can be guaranteed.

关 键 词：住院病历 病历修改 病历质量 闭环管理 

分 类 号：R7[医药卫生—临床医学]