提升医院病案管理质量的实践探索  

Experience in improving the quality of hospital medical record management

作　　者：陶然 李星 兰峻斌 Tao Ran;Li Xing;Lan Junbin(Xiamen Haicang Hospital,Xiamen 361026,Fujian Province,China)

机构地区：[1]厦门市海沧医院,厦门361026

出　　处：《中国医疗管理科学》2022年第4期44-47,共4页Chinese Journal Of Medical Management Sciences

摘　　要：目的探讨如何提升医院病案管理质量。方法通过专家咨询法、头脑风暴法,找出影响病案管理质量的因素,在健全相关制度、提升医生思想认识、完善信息系统、加大培训力度等方面加强管理,体现信息化技术在提高病案质量管理水平和持续改进医疗质量方面的效果。结果通过建立更加完整的病案质量管理体系,能够实时跟进病案质量的监管,减少病案质量管理过程中的缺漏和失误。结论信息化技术有助于提高医务人员的工作质量和效率,对于提高病案质量,减少医疗风险具有重要意义。Objective To explore effective means to improve the quality of hospital medical record management(HMRM).Methods Factors affecting HMRM were identified by expert consultation and brainstorming method.HMRM was strengthened by establishing relevant systems and policies,enhancing the awareness of clinicians,optimizing the information system,and intensifying stafftraining.In particular,the efficacy of information technology(IT)on the continuous improvement in the quality of HMRM and medical service was embodied.Results The establishment of a more complete HMRM system achieved the real-time monitoring of medical record quality and reduced errors and missed record in HMRM.Conclusions IT helps to improve the work quality and efficiency of the medical staff,and is of great significance for improving the quality of medical records and reducing medical risks.

关 键 词：病案质量管理 医疗质量 信息化技术 持续改进 

分 类 号：R197[医药卫生—卫生事业管理]