CAJ | 학술논문

目的：探索病案数字化翻拍技术的质量控制措施，评价全程质量管理对翻拍病案质量的影响。方法：采取强化以病案管理人员为主导的全程质量控制模式、规范数字化翻拍流程、对翻拍员进行病案信息常识指导、建立质量检查工作站、形成三级质检反馈制度等手段，建立一个纵横交错、严密有序的病案数字化质量管理网络。比较干预前后数字化病案的质量变化。结果：设置人为干预和系统干预后总的质检图像合格率由94.62%提高到98.59%，且有统计学差异（р<0.0001）。结论：全程质量控制程序，对提高数字化病案质量作用显著，有效保证翻拍病案质量，在实际应用中可最小程度依赖病案原件。
목적：탐색병안수자화번박기술적질량공제조시，평개전정질량관리대번박병안질량적영향。방법：채취강화이병안관리인원위주도적전정질량공제모식、규범수자화번박류정、대번박원진행병안신식상식지도、건립질량검사공작참、형성삼급질검반궤제도등수단，건립일개종횡교착、엄밀유서적병안수자화질량관리망락。비교간예전후수자화병안적질량변화。결과：설치인위간예화계통간예후총적질검도상합격솔유94.62%제고도98.59%，차유통계학차이（р<0.0001）。결론：전정질량공제정서，대제고수자화병안질량작용현저，유효보증번박병안질량，재실제응용중가최소정도의뢰병안원건。
Objective: Quality control measures to explore digital copying technology records,effect of whole process quality management evaluation on a remake of the quality of medical records. Methods: To strengthen the quality control mode to the medical record management as the dominant、specification of digital copying process、medical records information knowledge guidance to remake、the establishment of quality inspection start in、the formation of three quality inspection and Feedback system, establish a strict and orderly arranged in a crisscross pattern,the digital medical record quality management network. Results:Set up artificial intervention and after intervention quality inspection system image total qualified rate increased form 94.62%to 98.59%, and there were significant differences(P<0.0001).Conclusion: The whole quality control program, significant to improve the quality of digital medical record, effectively guarantee there make of medical record quality, in the practical application of minimal dependence on the original medical records.