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目的研究开发基于病案质控功能的电子病案系统,为医院医疗质量控制提供有效手段。方法将卫生部颁发的《病历书写基本规范》中各项规定融入到电子病案系统中,对医生的病历书写进行规范。结果电子病案系统中加入病案质量监控功能,实施医师、科室、病案室三级质控,使手写病历中常见的,如书写超时限、书写频次不够、医嘱中的检验项目缺少相应结果基本问题得以杜绝,基本消除丙级、乙级病历,大幅提高我院病案质量。结论通过在电子病案系统中加入病案质量控制功能,可以根本解决医院病历质量问题。
Objective To research and develop an electronic medical records system based on the quality control of medical records and provide an effective means for medical quality control in hospitals. Methods All the provisions in the “Basic Medical Records Writing Regulations” issued by the Ministry of Health were incorporated into the electronic medical record system to regulate the medical records writing of the doctors. Results In the electronic medical record system, the medical records quality monitoring function was added. The quality control of physicians, departments and medical records rooms was implemented. The common problems in handwritten medical records were that the writing time limit was insufficient, the frequency of writing was not enough, and the test items in medical orders lacked corresponding results. Put an end to basically eliminate C, B medical records, a substantial increase in the quality of medical records in our hospital. Conclusion By adding the medical record quality control function to the electronic medical record system, the medical record quality problem can be fundamentally solved.