摘要
病案数字化管理系统颠覆了传统纸质病案管理系统,使病案更加安全,存储空间更节约,信息利用、复印工作更高效。但对病案数字化下的质控提出更高的要求,需要对病案原件的顺序、完整性进行质控,保证病案的顺序及完整;对病案扫描件的扫描质量、完整性、信息准确性进行质控,对于质控内容下的纸张尺寸异常、粘贴不满意,内容错误、资料迟归,扫描件因扫描人员素质导致质量不佳的问题,采取以下措施:多方沟通合作,规范粘贴方式,统一病案纸张规格;完善相关制度,统一处理方法;加强数字化工作人员培训,探讨解决途径,总结经验。尽早厘清病案数字化管理流程中的各个关键环节,严抓质控要点的落实,以保证病案数字化工作质量。
The digital medical record management system changed the traditional paper medical record management system greatly.The digital medical record management system made the medical record management more secure and saved more storage space.It also made information utilization and medical records copying more efficient.However,the digital medical record management system required higher level of quality control,and the quality control on sequence and integrity of the original medical records were needed to ensure the correct sequenceand integrity of the medical records.The following measures were taken to ensure good quality and integrity of medical records scan,the accuracy of medical records scan and to solve the problems of the abnormal paper size according to quality control standards,the dissatisfaction of medical records paste,the error of medical record content,the late return of medical data,the poor quality of the scanning due to the staff quality:The more multi-party communications,the standard paste methods and unified medical records paper specifications were conducted.The related medical records management systems were improved,and the management methods were unified.The training of digital staff were strengthened.The methods of solving problems were explored,and the experiences were summarized.The key links of the digitalized management of medical records were clarified as soon as possible and the key points of quality control were strictly implemented to ensure the digital work quality of medical records.
作者
朱建国
程玉梅
Zhu Jianguo;Cheng Yumei(Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing 100026, China)
出处
《中国病案》
2018年第12期20-23,共4页
Chinese Medical Record
关键词
病案数字化
病案质控
病案扫描
Medical record digitization
Medical record quality control
Medical record scanning
