三级公立医院绩效考核背景下病案信息管理系统建设存在的问题与对策研究  

Problems in and countermeasures formedical records management systemin the context of performance appraisal in tertiary public hospitals

作　　者：侯娜娜 沈亮[2] 陆玉莹 谢明 刘清海 HOU Na’na;SHEN Liang;LU Yuying;XIE Ming;LIU Qinghai(Eye&ENT Hospital of Fudan University,Shanghai 200031,China;Longhua Hospital,Shanghai University of Traditional Chinese Medicine,Shanghai 200032,China)

机构地区：[1]复旦大学附属眼耳鼻喉科医院,上海200031 [2]上海中医药大学附属龙华医院,上海200032

出　　处：《现代医院》2023年第5期717-719,722,共4页Modern Hospitals

基　　金：上海申康医院发展中心临床科技创新项目(SHDC12021607)。

摘　　要：在国家三级公立医院绩效考核和新冠肺炎疫情加剧的环境下,病案信息管理系统对于医院医疗工作正常开展和运营管理的保障作用益发凸显。针对部分三级公立医院在病案信息化建设中存在管理层面和法律制度认知不足、病案信息系统功能较不完善尤其缺乏病案的全流程质控功能等问题,文章提出优化医院病案信息系统相关的制度和标准以及相关的专业人才队伍、多部门协调完善病案信息系统建设,利用互联网技术研发从事前预防、事中管控、事后检验,实现“全方面、全流程”病案质量控制管理模式,从而提高病案资源的利用效率,为我国的医院高质量发展持续推进奠定坚实基础。Under the background of the performance appraisal in tertiary public hospitals and the intensifying COVID-19 epidemic,the role of the management system of medical record information in the normal development and operations management of hospital medical work has been pronounced.In view that some tertiary public hospitals have problems in the information construction of medical records,such as insufficient awareness of management level and legal system,imperfect function of the medical record information system,and especially lack of quality control function of the whole process of medical records,this paper aims to optimizethe systems and standards related to hospital medical record information system,building a professional talent team related to these professions,and developing a medical record information system for multi-department coordination.It advocates to realize the“all aspects,the whole process”management mode of medical record quality by performing pre-prevention,in-process control,post-inspection by using Internet technology so as to improve the utilization efficiency of medical record resources and lay a solid foundation for the continuous promotion of high-quality development of hospitals in China.

关 键 词：病案信息管理系统 国家三级公立医院绩效考核 病案质量控制 

分 类 号：R197.323.1[医药卫生—卫生事业管理] R319[医药卫生—公共卫生与预防医学]