摘要
目的通过计算机技术实现病历质量的全程监控,特别是运行病历的实时监控,提高病历书写质量。方法以结构化电子病历为依托,以时间、医嘱、模板调用等为控制节点,实现病历质控自动化。结果通过计算机进行质量控质,可以扩大病历质量控制的范围,实现实时、标准化的病历质量控制。结论计算机技术可提高病历质量监控的质量和效率,是将来病历质量控制的方向。
Objectives Through computer technology to achieve whole course of medical records quality,especially the real-time monitoring of running medical records,it can improve writing quality of medical records.Methods Relying on structural electronic medical records,it achieves medical records quality control automation,using time,medical orders and template as control node.Results Through quality control by computer,it can enlarge the range of medical records quality control for achieving real-time,standardization medical records quality control.Conclusions Computer technology can improve the quality and efficiency of quality monitoring of medical records that is a direction of future quality control of medical records.
出处
《中国病案》
2012年第1期27-28,共2页
Chinese Medical Record
关键词
结构化
电子病历
质量控制
Structure
Electronic medical record
Quality control
