基于医疗质量与安全考核系统的病案质量管理分析与改进
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摘要
病案质量在医疗质量中起着基础而重要的作用。为进一步做好病案质量管理,医院结合原有HIS、EMRS和病案管理系统新开发了医疗质量与安全考核系统,增设病案质量管理指标和分值,纳入科室绩效考核;整合相关系统的病案管理功能;优化运行病历、终末病历和延迟病历检查流程;实现螺旋式PDCA结果反馈、实时数据查询和统计图表生成。最后讨论了数据校对,多部门协作等问题。
Medical record quality plays a fundamental and important role in medical quality. In order to further improve the medical record quality management, a new medical quality and safety assessment system was developed which combined with original HIS, EMRS and the medical record management systems of our hospital. Indicators and grades of medical record quality management were added for department performance appraisal. Related systems' functions on medical record management were integrated. Review procedures of running, terminal and delay filing medical records were optimized.The spiral PDCA was used in results' feedbacks. What's more real-time data query and statistical graphs were generated. Data proofreading, multispectral collaboration and other issues were discussed.
Medical record quality plays a fundamental and important role in medical quality. In order to further improve the medical record quality management, a new medical quality and safety assessment system was developed which combined with original HIS, EMRS and the medical record management systems of our hospital. Indicators and grades of medical record quality management were added for department performance appraisal. Related systems' functions on medical record management were integrated. Review procedures of running, terminal and delay filing medical records were optimized.The spiral PDCA was used in results' feedbacks. What's more real-time data query and statistical graphs were generated. Data proofreading, multispectral collaboration and other issues were discussed.
引文
[1]高峰,石建,董晓建.数字化病案管理系统的研究现状与发展趋势[J].中华医学图书情报杂志,2011,20(12):62-65.
[2]黄鹏,梁耀基,何丽萍.医院评审对病案管理工作的促进作用[J].中国病案,2012,13(3):8-10.
[3]谢子秋,方鹏骞.我国侵权责任法实施后对医疗行为变化的影响[J].医学与社会,2013,26(3):61-64.
[4]李莉.病历及时归档管理对诊断分类相关组的影响及医疗质量评价[J].中国医院,2015,19(3):69-71.
[5]李卫红,王宇,刘国华.构建多系统的病案管理功能模式[J].中国病案,2015,16(6):6-9.
[6]张萍,邱立,刘慧.大数据思维框架下医院“质量数据管理中心”的集成构建[J].中国医院,2015,19(3):30-32.
[7]吕建波,吕璐.河北省45家三级医院病案室现状调查研究[J].中国医院.2014,18(12):14-16.
[8]甄洪芳,李杨,李一童.提高病案编码员的工作能力势在必行[J].中国医院.2014,18(7):76-77.
[2]黄鹏,梁耀基,何丽萍.医院评审对病案管理工作的促进作用[J].中国病案,2012,13(3):8-10.
[3]谢子秋,方鹏骞.我国侵权责任法实施后对医疗行为变化的影响[J].医学与社会,2013,26(3):61-64.
[4]李莉.病历及时归档管理对诊断分类相关组的影响及医疗质量评价[J].中国医院,2015,19(3):69-71.
[5]李卫红,王宇,刘国华.构建多系统的病案管理功能模式[J].中国病案,2015,16(6):6-9.
[6]张萍,邱立,刘慧.大数据思维框架下医院“质量数据管理中心”的集成构建[J].中国医院,2015,19(3):30-32.
[7]吕建波,吕璐.河北省45家三级医院病案室现状调查研究[J].中国医院.2014,18(12):14-16.
[8]甄洪芳,李杨,李一童.提高病案编码员的工作能力势在必行[J].中国医院.2014,18(7):76-77.