摘要
针对病案管理存在的系统零散、信息缺乏完整性、信息化程度不高等问题,整合各子系统至临床医学数据平台,形成一体化病案管理信息系统。系统涵盖病案管理工作的各环节,实现了病案全程示踪、编码录入、质量监控、字典库维护、数字化归档和病案复印等功能,有效提高了病案管理工作质量和效率。通过优化病案管理流程,系统功能更加完善,结构更加优化,实用性和稳定性更强。改进病案管理流程,可有效提升病案管理水平,提高病案质量,保障医疗安全。
Aiming at the problems of systemic fragmentation,lack of information integrity and low degree of informationization,the subsystems were integrated into the clinical medical data platform to form an integrated medical record management information system.The system covered all aspects of the medical record management work,and realized the functions of the whole process of traceability,code entry,quality monitoring,dictionary database maintenance,digital archiving and medical record copying,which effectively improved the quality and efficiency of medical record management.By optimizing the medical record management process,the system functions were more complete,the structure was more optimized,and the practicality and stability were stronger.Improving the medical record management process can effectively improve the management level of medical records,improve the quality of medical records,and provide protection for medical safety.
作者
张晴晴
ZHANG Qingqing(Shandong Provincial Hospital Affiliated to Shandong University,Ji'nan,Shandong,250021,China)
出处
《中国卫生质量管理》
2019年第3期41-43,共3页
Chinese Health Quality Management
基金
山东省重点研发计划(2017GSF218092)
关键词
医疗质量
病案管理
临床医学数据平台
病案流程
Medical Quality
Medical Record Management
Clinical Medical Data Platform
Medical Record Process
