自动化病历质控系统应用效果评价  

Effect Evaluation of Automatic Medical Record Quality Control System

作　　者：徐芳[1] 郝雅斌[1] 牛宇翔 XU Fang;HAO Yabin;NIU Yuxiang(Beijing Friendship Hospital,Capital Medical University,Beijing 100050,China)

机构地区：[1]首都医科大学附属北京友谊医院,北京市100050

出　　处：《中国卫生信息管理杂志》2024年第3期464-470,共7页Chinese Journal of Health Informatics and Management

摘　　要：目的在病历信息化建设基础上,建立并优化自动化病历质控系统,对运行病历进行持续、动态、有效的监测,以提高病案质量。方法在北京某三级甲等医院中,以电子病历系统为基础,建立运行病历的质量控制和管理方案,对运行中的病历进行自动检测、分析和评价,并通过多种渠道反馈给医院及科室管理者,以便随时掌握运行病历的质量并及时应对。结果利用临床数据中心和移动互联网建立的自动化病历质控系统对运行病历的评分与人工抽检病历的评分结果基本一致,尚不能说明两种质控方式的评分结果有差异。2022年9月运行病历月合格率同比增长33.81%。研究期间,运行病历合格率的季度环比增长率为0.15%~18.12%。结论自动化病历质控系统可以有效提高病历质控的覆盖率和时效性,有助于规范病历书写,提高医疗质量,改善医疗服务和保障医疗安全。Objective To establish and optimize the automatic quality control system of hospital medical records on the basis of information construction,and to monitor the running medical records continuously,dynamically and effectively,so as to improve the quality of medical records.Methods Our study was carried out in one of the Grade-A Tertiary Hospitals in Beijing.A quality control and management scheme of running medical records was established on the basis of electronic medical record system.The quality control system automatically detected,analyzed and evaluated the running medical records,and fed the results back to the hospital leaders and department directors through a variety of channels,so that they could grasp the quality of running medical records and respond in time.Results There was no significant difference in the score of manual sampling medical record quality control and running medical record automatic quality control.The Monthly qualified rate of running medical records in September 2022 was 33.81% higher than that of 2021 in the same period.During the study period,the quarter-on-quarter growth rate of the qualified rate of running medical records was 0.15%-18.12%.Conclusion The running medical records quality control system can effectively improve the coverage and timeliness of medical records quality control.It is helpful to standardize the writing of medical records,strengthen medical quality,improve medical services and ensure medical safety.

关 键 词：自动化 病历质控系统 运行病历 

分 类 号：R-058[医药卫生] R319