以医疗质量安全核心制度为导向的分层管理模式在电子病历中的应用  

Application of Hierarchical Management Model Guided by Core System of Medical Quality and Safety in Electronic Medical Records

作　　者：王云红 公雪 王金凤[1] 谢海梅[1] 张红卫[1] Wang Yunhong;Gong Xue;Wang Jinfeng;Xie Haimei;Zhang Hongwei(Beijing Luhe Hospital,Capital Medical University,Beijing 101100,China)

机构地区：[1]首都医科大学附属北京潞河医院,北京市101100

出　　处：《中国病案》2025年第1期10-13,共4页Chinese Medical Record

摘　　要：目的将医疗质量安全核心制度为导向的分层管理模式运用于电子病历系统的搭建中,为提高住院电子病历书写质量提供有效方法。方法通过对文献的归纳及总结,以医疗质量安全核心制度为导向,构建以基本逻辑校验为基础,内涵质控为核心的贯穿环节和终末的院科两级多维度质控模式,对某院2023年10月1日-2024年4月30日的住院病案进行环节质控。结果及时性相关的5个指标在质控模式应用后的差异均具有统计学意义,病历书写及时率明显提高,1个工作日归档率由初始的95.31%提升至99%;科室质控2个指标,在模式应用前后均有统计学差异,科室质控率由19.07%上升至82.31%,发现问题率由45.61%降低至30.84%。院级内容质控的6个指标,在模式应用前后的差异均具有统计学意义,病案完整率、诊断正确率、手术正确率、病程记录规范率、入院记录规范率、出院(死亡)记录规范率分别由运用分层管理模式前的99.6%、98.54%、98.17%、97.72%、98.54%、95.27%上升至99.87%、99.74%、99.59%、99.14%、99.74%、98.77%。结论以医疗质量安全核心制度为导向的分层管理模式能够有效提升医疗服务质量,减少病案质控缺陷,提高病案书写效率和质量。Objectives This study aims to analyze the application of the hierarchical management model guided by the core system of medical quality and safety in the construction of the electronic medical record system,providing an effective method to improve the quality of electronic medical record writing for inpatients.Methods Through a review and summary of the literature and guided by the core system of healthcare quality and safety,a multi-dimensional,two-level quality control model—covering both departmental and hospital levels—was developed.This model is based on fundamental logic verification and centers on internal quality control throughout all stages,including final review.It was applied to inpatient medical records at a certain hospital from October 1,2023,to April 30,2024,for stage quality control.Results The differences in the five indicators of time efficiency were statistically significant after the application of quality control mode.The timeliness of medical record writing was significantly improved,and the filing rate within one working day increased from the initial 95.31%to 99.00%.There were statistical differences in the two indicators of department quality control before and after the application of the model.The department quality control rate increased from 19.07%to 82.31%,and the problem detection rate decreased from 45.61%to 30.84%.The differences in the six indicators of hospital-level content quality control before and after the model application were statistically significant.The completeness rate of medical records,diagnosis accuracy rate,surgical accuracy rate,standardization rate of medical records,standardization rate of admission records,and standardization rate of discharge(death)records increased from 99.6%,98.54%,98.17%,97.72%,98.54%,and 95.27%before the implementation of the hierarchical management model to 99.87%,99.74%,99.59%,99.14%,99.74%,and 98.77%,respectively.Conclusions The hierarchical management model guided by the core system of medical quality and safety can effectively

关 键 词：电子病历 质控 重点病历管理 

分 类 号：R197.323[医药卫生—卫生事业管理]