CAJ | 학술논문

目的利用信息系统对住院电子病历进行环节质量控制,提高质控管理工作的效率和精细化程度;通过质控系统进行医疗质量指标数据的统计与分析.方法将电子病历与医嘱、麻醉、检验、影像、超声等系统建立接口、实现数据共享,采集诊疗事件和时间节点,设计出针对环节和时限的质控模块、进行相关医疗质量指标数据的统计与分析.结果设计开发的质控系统具备六个质控工具;一个科内医生病历审核系统;危重症报告与评分等上报管理系统;能够对关注的医疗质量指标数据进行统计分析.结论住院电子病历环节质量控制系统的设计功能全面,符合卫生部《病历书写基本规范》与《电子病历基本规范》的要求,能够满足《三级综合医院评审标准(2011年版)》对病历质控管理的相关要求;利用质控工具能够实现病历的全面质控和重点质控.
목적이용신식계통대주원전자병력진행배절질량공제,제고질공관리공작적효솔화정세화정도;통과질공계통진행의료질량지표수거적통계여분석.방법장전자병력여의촉、마취、검험、영상、초성등계통건립접구、실현수거공향,채집진료사건화시간절점,설계출침대배절화시한적질공모괴、진행상관의료질량지표수거적통계여분석.결과설계개발적질공계통구비륙개질공공구;일개과내의생병력심핵계통;위중증보고여평분등상보관리계통;능구대관주적의료질량지표수거진행통계분석.결론주원전자병력배절질량공제계통적설계공능전면,부합위생부《병역서사기본규범》여《전자병력기본규범》적요구,능구만족《삼급종합의원평심표준(2011년판)》대병력질공관리적상관요구;이용질공공구능구실현병력적전면질공화중점질공.
Objective To realize the procedure quality control of electronic medical record by information system ,and to improve the efficiency and the refinity of quality control management .Statistics and analysis of medical treatment quality data can be obtained by the quality control system .Meth-ods Data sharing by the connection of electronic medical records and several other systems ,such as medical order ,anesthesia ,laboratory ,image ,and ultrasound .Col ect the diagnosis and treatment affairs and time points ,design the quality control models of the procedures and time points ,and then make the statistics and analysis of the relative medical treatment quality data .Results The quality control system contains six instruments ,a medical record examining system ,and a report management system of critical y il ness reported and scored .It makes the statistic and analysis of the medical treatment quality data feasible .Conclusion The functional design of the electronic medical record quality control system is comprehensive .It accord with the standards of Ministry of Health “medical record writing basic norm” and “electronic medical record basic norm” .It can satisfy with the re-quirements of medical record quality control management of “tertiary general hospital evaluation standard (2011 edition)” .We can realize comprehen-sive medical quality control and key quality control by the quality control system .