以病案质控管理为目标的住院病历无纸化归档体系建设实践  

Development and application of paperless archiving system for inpatient medical records with the goal of quality control and management of medical records

作　　者：孔勤[1] 徐新[1] 邓卓 赵成松[1] KONG Qin;XU Xin;DENG Zhuo;ZHAO Chengsong(Information Center,Beijing Children's Hospital,Capital Medical University,Beijing 100045,China)

机构地区：[1]首都医科大学附属北京儿童医院信息中心,北京100045

出　　处：《中国数字医学》2024年第10期70-77,共8页China Digital Medicine

摘　　要：目的:借助信息化手段提升病案质量和管理效率,实现住院病历归档的全生命周期智慧化管理。方法:以问题为导向,对某院病历归档管理流程进行深入调研与需求分析,通过建立无纸化归档闭环管理机制、文书完整性卡控机制、病案修改审核管理机制、可靠电子签名架构,构建以临床业务系统、归档系统、电子签名系统为一体的住院病历无纸化归档全流程闭环管理体系。结果:已实现24项医技报告、12种医护文书的无纸化归档,覆盖住院归档病历范围的90.00%以上,病历无纸化自动归档率96.13%,病历归档完整率达100.00%,杜绝了纸质病历缺张少页的安全隐患。结论:住院病历无纸化归档体系的建设,有效提升现代医院病案质控管理水平,进一步助力公立医院高质量发展。Objective To improve the quality and management efficiency of medical records by means of information technology,and realize the intelligent management of the whole life cycle of inpatient medical record archiving.Methods A problem-oriented in-depth investigation and demand analysis were carried out on the medical record archiving management process of a hospital,and a whole-process closed-loop management system for paperless archiving of inpatient medical records integrated with clinical business system,archiving system and electronic signature system was constructed by establishing a paperless archiving closed-loop management mechanism,a document integrity card control mechanism,a medical record modification and review management mechanism,and a reliable electronic signature architecture.Results The paperless archiving of 24 medical technical reports and 12 kinds of medical documents was realized,covering more than 90.00%of the scope of inpatient archived medical records.The paperless automatic archiving rate of medical records was 96.13%,and the complete archiving rate of medical records was 100.00%,eliminating the potential risks of missing pages in paper medical records.Conclusion The construction of the paperless archiving system of inpatient records can effectively improve the quality control and management level of medical records in modern hospitals,and further promote the high-quality development of public hospitals.

关 键 词：无纸化归档 病历归档全流程闭环管理 电子签名 病案质控管理 

分 类 号：R197.3[医药卫生—卫生事业管理] R319[医药卫生—公共卫生与预防医学]