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目的监控病案信息质量,提高医院管理水平。方法针对病案产生过程中容易出现的各种逻辑错误,利用统计系统的综合查询菜单,自主编写SQL语句,建立多个查询纠错模板,对病案信息进行逻辑检查。结果提供了新的质量监控手段,方便了病案首页信息录入人员自查,也方便了管理者质控监督,实现了信息统计对病案信息录入工作的监督。结论极大地提高了病案首页信息的录入质量,使各种统计报表上报及时,准确完整。
Objective To monitor the quality of medical record information and improve the hospital management level. Methods According to the logic errors prone to occur in the medical records, we use the comprehensive query menu of the statistical system to write the SQL statements autonomously, establish multiple query error correction templates and logically check the medical record information. The results provide a new means of quality control and facilitate the self-examination of the first page of information on the medical records, as well as the quality control of the supervisors and the supervision of information statistics on the entry of medical records. The conclusion has greatly improved the input quality of the first page of the medical record, and timely and accurately reporting the various statistical reports.