病案多维度终末质控工作的实践与思考  

Practice and Thinking of Multidimensional Final Quality Control of Medical Records

作　　者：吕亚奇 曾跃萍[1] 宋菲 田明月[1] 陈燕华[1] 张欣[1] LYU Ya-qi;ZENG Yue-ping;SONG Fei(National Center for Children's Health,Beijing Children's Hospital,Capital Medical University,Beijing 100045,P.R.C.)

机构地区：[1]国家儿童医学中心,首都医科大学附属北京儿童医院,北京市西城区100045

出　　处：《中国数字医学》2020年第12期81-84,共4页China Digital Medicine

摘　　要：目的:随着DRG(Diagnosis Related Groups)付费工作的推进,病案质量控制显得尤为重要,本研究结合已有病案终末质控工作,总结已有优点,思考尚存缺陷、解决方法以及工作方向。旨在更高效地开展病案质控工作,为DRG准确分组、精准付费评估奠定基础。方法:通过绘制工作流程图清晰表述病案终末质控的路径,通过总结各环节终末质控内容对正在实行的工作量和时间节点进行评估整合。结果:已有质控虽分布在多个环节,但仍存在较多管理问题,经过初步流程改进,质控效果有所改善。结论:需要整合质控分工,合理利用已有电子病历资源,结合数据分析扩展质控数据应用空间。Objective:Significances of quality control for medical records are apparent during era hospitalization cost payed by DRG(Diagnosis Related Groups)system.It is very necessary to raise efficiency of quality control for more accurate DRG partitioning.Methods:Route of quality control for medical records was drawn by flow diagram.Quality controls in each link were described by form.Results:The links of quality control were enough.However,there were some problems.The quality control effect has been improved by initial modification for process.Conclusion:Division of quality control would be integrated.Existing electronic medical record(EMR)system should be rational utilization.Application space of quality control data may be expanded by data analysis.

关 键 词：病案管理 终末质控 流程思考 电子病历 

分 类 号：R319[医药卫生—基础医学]