基于临床医学数据平台优化病案管理流程
|
摘要
针对病案管理存在的系统零散、信息缺乏完整性、信息化程度不高等问题,整合各子系统至临床医学数据平台,形成一体化病案管理信息系统。系统涵盖病案管理工作的各环节,实现了病案全程示踪、编码录入、质量监控、字典库维护、数字化归档和病案复印等功能,有效提高了病案管理工作质量和效率。通过优化病案管理流程,系统功能更加完善,结构更加优化,实用性和稳定性更强。改进病案管理流程,可有效提升病案管理水平,提高病案质量,保障医疗安全。
Aiming at the problems of systemic fragmentation,lack of information integrity and low degree of informationization,the subsystems were integrated into the clinical medical data platform to form an integrated medical record management information system.The system covered all aspects of the medical record management work,and realized the functions of the whole process of traceability,code entry,quality monitoring,dictionary database maintenance,digital archiving and medical record copying,which effectively improved the quality and efficiency of medical record management.By optimizing the medical record management process,the system functions were more complete,the structure was more optimized,and the practicality and stability were stronger.Improving the medical record management process can effectively improve the management level of medical records,improve the quality of medical records,and provide protection for medical safety.
Aiming at the problems of systemic fragmentation,lack of information integrity and low degree of informationization,the subsystems were integrated into the clinical medical data platform to form an integrated medical record management information system.The system covered all aspects of the medical record management work,and realized the functions of the whole process of traceability,code entry,quality monitoring,dictionary database maintenance,digital archiving and medical record copying,which effectively improved the quality and efficiency of medical record management.By optimizing the medical record management process,the system functions were more complete,the structure was more optimized,and the practicality and stability were stronger.Improving the medical record management process can effectively improve the management level of medical records,improve the quality of medical records,and provide protection for medical safety.
引文
[1]何萍,马凌云,赵蓉.区域性电子病案数据中心的建设与应用[J].中国数字医学,2015,10(2):8-11.
[2]刘婷,唐其柱.基于信息平台提升病案首页质量的实践[J].中国卫生质量管理,2017,24(4):76-80.
[3]李凤君.病案示踪系统在病案流通过程中的建立和应用[J].中国病案,2012,13(11):13-15.
[4]何建权,王华,陈张慧,等.全程病案示踪管理系统设计与应用[J].医学信息学杂志,2016,37(12):26-29.
[5]周岩,孙明,刘红,等.利用身份证阅读器改进病案复印工作[J].中国病案,2015,16(5):6-7.
[6]王玲,刘文杰,胡剑超,等.出院病案追踪管理系统的开发与应用[J].中国病案,2011,12(6):42.
[7]李卫东,陈永枫.某部队医院数字化病案管理系统的应用和改进[J].实用医药杂志,2016,33(7):660-661.
[8]郝育鹏,季新强,王彦晨,等.住院病案首页操作信息自动提取的实践[J].中国病案,2017,18(7):44-46.
[9]徐晓兰,周传军.谈病案借阅管理中存在的问题与对策[J].中国病案,2012,13(5):8-9.
[10]雷秀英.病案利用情况分析[J].中国医院统计,2008,15(1):86-87.
[2]刘婷,唐其柱.基于信息平台提升病案首页质量的实践[J].中国卫生质量管理,2017,24(4):76-80.
[3]李凤君.病案示踪系统在病案流通过程中的建立和应用[J].中国病案,2012,13(11):13-15.
[4]何建权,王华,陈张慧,等.全程病案示踪管理系统设计与应用[J].医学信息学杂志,2016,37(12):26-29.
[5]周岩,孙明,刘红,等.利用身份证阅读器改进病案复印工作[J].中国病案,2015,16(5):6-7.
[6]王玲,刘文杰,胡剑超,等.出院病案追踪管理系统的开发与应用[J].中国病案,2011,12(6):42.
[7]李卫东,陈永枫.某部队医院数字化病案管理系统的应用和改进[J].实用医药杂志,2016,33(7):660-661.
[8]郝育鹏,季新强,王彦晨,等.住院病案首页操作信息自动提取的实践[J].中国病案,2017,18(7):44-46.
[9]徐晓兰,周传军.谈病案借阅管理中存在的问题与对策[J].中国病案,2012,13(5):8-9.
[10]雷秀英.病案利用情况分析[J].中国医院统计,2008,15(1):86-87.