摘要
目的探索解决病案延期归档或无纸化时病案首页质控问题。方法依靠现有平台,采用C/S架构设计,采用DELPHI开发工具开发的病案管理系统可以实现军队医院首页网络质控。结果编目的同时进行病案首页质控,保证时效性,人工核查与计算机智能核查保证准确性,并利用系统自动登记病案首页质控,为千分考核提供依据。结论病案管理系统实现编目员在线编码、网络质控,确保病案首页质量准确性,提高了工作效率,解决了病案无纸化进程中的一大难题。病案无纸化推动传统病案管理模式的不断创新与持续改进。病案管理流程与相关配套软件要配合无纸化进程不断优化。
Objective To explore the methods to solve delayed archiving of medical records or the quality control problems of home pages in paperless medical records. Methods Depend on the current platform, with the application of medical record management system designed by C/S architecture and developed by DELPHI, the online quality control on the home pages of medical records could be realized. Results To conduct quality control on the home pages of medical records while coding to ensure timeliness, computer examination and artificial checking to ensure the accuracy, and register the quality control results of medical results of medical records the system automatically,so as to provide evidence for the millesimal examination. Conclusions The management system of medical records realized online coding and quality control, ensured the accuracy of the quality, improved work efficiency and solved a big problem in the process of paperless medical records. Paperless medical records promote the traditional medical record management model innovation and continuous improvement. Processes of medical record management and supporting software should be continuous optimization following the process paperless.
出处
《中国病案》
2016年第1期8-9,共2页
Chinese Medical Record
关键词
军队
病案首页
网络质控
无纸化
Army
Home pages of medical records
Online quality control
Paperless
