探讨大数据时代如何加强病案质控管理  

Exploring Strategies to Enhance the Oversight and Governance Processes Pertaining to Case File Integrity within Community-based Hospitals Amidst the Age of Big Data

作　　者：魏燕玲 杨静[2] 易淑芳 WEI Yanling;YANG Jing;YI Shufang(Department of Medical Record,The First People´s Hospital of Yumen City,Yumen 735211,Gansu,China;Department of Quality Control,The First People´s Hospital of Jiayuguan City,Jiayuguan 735100,Gansu,China;Department of Medical Record,Dunhuang Hospital,Dunhuang 736200,Gansu,China)

机构地区：[1]玉门市第一人民医院病案科,甘肃玉门735211 [2]嘉峪关市第一人民医院质控科,甘肃嘉峪关735100 [3]敦煌市医院病案科,甘肃敦煌736200

出　　处：《中国卫生产业》2024年第18期131-134,共4页China Health Industry

摘　　要：本文主要分析了大数据时代下医院病案质控存在的各种问题,如整体数据质量不高,医院层面对病案管理不重视,临床医护人员重治疗轻病案记录,病案质量管理人员专业素质有待进一步提升、使用的疾病和手术编码数据库不规范、各类病案数据资料上传前无核对、管理欠缺科学性、病案诊断信息不规范、医护人员和病案质量管理人员培训不到位等各种问题,针对问题提出了如何从加强内部管理与内部监督、创建病案数据系统等方面加强病案质控管理,希望能为相关人员提供一定参考和借鉴。This paper mainly analyses various problems existing in the quality control of hospital medical records in the era of big data,such as low overall data quality,lack of attention to medical record management at the hospital level,emphasis on treatment and low attention to medical record recording by clinical medical staff,and low quality of medical records.The professional quality of medical record quality management personnel needs to be further improved,the disease and surgical coding databases used are not standardized,all kinds of medical record data are not verified before uploading,the management is not scientific,the medical record diagnosis information is not standardized,and the training of medical staff and medical record quality management personnel is not in place.In view of the problem,this paper summarizes how to strengthen the quality control management of medical records from the aspects of strengthening internal management and internal supervision,creating medical records data system,etc.,hoping to provide some reference for relevant personnel.

关 键 词：大数据 病案管理 质量控制 

分 类 号：R192[医药卫生—卫生事业管理]