摘要
目的探讨提高电子病历质量的管理规范。方法实时监测系统对病历生成环节进行质量控制,对重点多发问题分类立项检查评比,比较不同阶段电子病历的质量。结果与2005年相比,2006年上半年,电子病历质量显著提高(P<0.01),特点为不及时完成率降为0.2%(P<0.01),不及格病历率降为1.3%(P<0.01)。结论病历环节质控管理是提高病历质量的有效途径,各级职能部门的严格管理和考核,加上各级临床医生的重视,是提高病历质量的关键。
Objective To explore the means of improving the quality of computer- based medical records. Methods The factors influencing the quality of computer- based medical records were respectively evaluated by comparison the quality of computer- based medical records in different periods. Results Comparison with 2005, the quality of medical records in prior six months in 2006 improved markedly（ P 〈0.01）, characterized by 0.2% of un-timing medical records and 1.3% of substandard medical records.Conclusions real-time monitoring - feedback is an important means of improving quality of computer- based medical records.
出处
《武警医学》
CAS
2007年第1期33-36,共4页
Medical Journal of the Chinese People's Armed Police Force
关键词
环节质控
电子病历
质量管理
Step- by- step managemant of quality Electric medical record Quality management
