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某基层医院在信息化进程中对传统病案质控流程进行升级改造,形成了事前建立质量控制标准规则、事中进行运行病案质控、事后终末质控的闭环病案质控管理流程。新流程强化了质控管理手段,使病案质控更加科学、合理,提高了病案质量,保障了医疗安全,提升了质控人员的工作效率。在对新质控流程使用过程中存在的雷同病历、病历时效性差、越级使用签名等病案质量问题进行梳理与分析后,思考基层医院病案质控问题的原因,并根据某院的实际情况在行政管理、职业教育和软件技术层面提出解决措施。研究旨在使用科学的手段加强病案质量管理,探索基层医院电子病历质控的合理方式,在完善管理模式的基础上加强电子病历的信息化建设进程,更好地提高病案的开发利用价值,从而为患者、医院和社会提供多方面的服务。
A grass-roots hospital in the process of information technology to upgrade the traditional quality control flow control process, the formation of the standard rules of quality control in advance, in the operation of the medical record quality control, post-mortem quality control closed loop case management process. The new process has strengthened the quality control management measures, made the quality control of medical records more scientific and reasonable, improved medical record quality, ensured medical safety and improved the quality control staff’s work efficiency. After reviewing and analyzing the medical record quality problems such as the same medical record, poor medical record timeliness and the use of signatures in the process of using the new quality control process, we think about the reason of the quality control problem in the primary hospital and according to the actual situation in a hospital, Management, vocational education and software technology to put forward solutions. The purpose of this study is to use scientific methods to strengthen the quality management of medical records and to explore reasonable ways of quality control of electronic medical records in primary hospitals. Based on the improvement of management models, the progress of informatization of electronic medical records should be strengthened so as to enhance the value of medical records utilization and development. For patients, hospitals and society to provide a wide range of services.