基于信息化的病案管理质量控制指标监测策略与实践  

Monitoring Strategy and Practice of Quality Control Indicators for Medical Record Management Based on Informatization

作　　者：张敏敏 毛淋淇 高卫益[1] 金瑞[1] Zhang Minmin;Mao Linqi;Gao Weiyi(Ruijin Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai,200025,China;不详)

机构地区：[1]上海交通大学医学院附属瑞金医院,上海200025

出　　处：《中国医院管理》2025年第5期80-82,共3页Chinese Hospital Management

基　　金：上海申康医院发展中心市级医院诊疗技术推广及优化管理项目(SHDC22024220)。

摘　　要：为解决病案内涵质控指标监测工作中存在的人工质控耗时耗力、人工智能技术难以准确评估的两难问题,案例医院借助信息技术制定了适宜的监测策略。针对病历书写时效性指标,可采取从电子病历系统直采数据的方式进行自动全量监测;9项非书写时效性指标,可通过与常规病案督查扣分项智能联动的方法自动判定结果。信息技术的应用有利于提高指标监测效率和数据采集质量,为病案质量精细化管理提供数据支撑。To solve the dilemma of manual quality control time-consuming and labor-intensive,and artificial intelligence technology being difficult to accurately judge in the monitoring of medical record connotation quality control indicators,the case hospital has developed an appropriate data monitoring strategy with the help of information technology.For the timeliness indicators of medical record writing,full monitoring can be carried out by directly collecting data from the electronic medical record system.Nine indicators of non-timeliness indicators can be automatically judged through intelligent linkage with the deduction items of routine medical record supervision.The application of information technology is conducive to improving the efficiency of index monitoring and the quality of data collection,providing data support for the refined management of medical record quality.

关 键 词：病案管理质量控制指标 信息技术 数据监测 

分 类 号：R197.323.1[医药卫生—卫生事业管理]