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目的加强病案质量管理。采用分时段实时监控方法,及时发现电子病案存在的缺陷,采取考评信息反馈,促进电子病案质量的提高。方法通过医院病人信息查询系统,对全院电子病案质量进行实时监控分析,了解首次病程记录、入院病历、三级检诊完成时限。结果电子病案大多存在不良拷贝、书写、打印不及时、上级医师审签时限滞后等问题。结论通过电子病案质量实时控制,可以加强病案质量环节管理,强化依法行医质量意识,为终末病案质量提高奠定基础。
Objective To strengthen medical records quality management. Using sub-time real-time monitoring methods, timely detection of defects in electronic medical records, take evaluation feedback, and promote the improvement of the quality of electronic medical records. Methods Through the hospital patient information query system, the hospital electronic medical record quality real-time monitoring and analysis, to understand the first course of the record, admission medical records, three check-in time limit. As a result, most of the electronic medical records have such problems as bad copies, writing and printing in time, delays in the examination of superior physicians. Conclusion The real-time control of the quality of electronic medical record can strengthen the management of medical record quality and strengthen the sense of quality of medical practice in accordance with the law, laying a solid foundation for improving the quality of the final medical record.