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目的探索解决病案延期归档或无纸化时病案首页质控问题。方法依靠现有平台,采用C/S架构设计,采用DELPHI开发工具开发的病案管理系统可以实现军队医院首页网络质控。结果编目的同时进行病案首页质控,保证时效性,人工核查与计算机智能核查保证准确性,并利用系统自动登记病案首页质控,为千分考核提供依据。结论病案管理系统实现编目员在线编码、网络质控,确保病案首页质量准确性,提高了工作效率,解决了病案无纸化进程中的一大难题。病案无纸化推动传统病案管理模式的不断创新与持续改进。病案管理流程与相关配套软件要配合无纸化进程不断优化。
Objective To explore and solve the problem of quality control on the first page of medical record when the medical record is postponed or archived. Methods Rely on the existing platform, the use of C / S architecture design, the use of DELPHI development tools to develop the medical record management system can be achieved in the hospital network home network quality control. Results cataloging at the same time the first case of medical record quality control, timeliness, manual verification and computer intelligent verification to ensure accuracy and use of the system automatically register the first page of medical records quality control, to provide the basis for the thousand assessment. Conclusion The medical records management system realizes catalogers’ online coding and network quality control to ensure the accuracy of the first page of medical records and improve the work efficiency, thus solving a major problem in the process of paperless medical records. Paperless medical records promote the continuous innovation and continuous improvement of traditional medical records management. Medical records management processes and related software to cooperate with the process of paperless optimization.