摘要
目的探讨HIMSS7级信息化在JCI归档病历审查的应用价值。方法对比第5版、第6版“JCI归档病历审查表”;在医院HIS病案管理系统“终末质控统计报表”导出2018年1月—2019年1月的终末质控病历数;分析历次JCI评审所抽查归档病历。运用Excel2007软件对数据进行统计分析。结果第6版“JCI归档病历审查表”比第5版总评分项增加10项;经过信息系统改造,2018年1月—2019年1月JCI相关四类典型问题下降显著;历次JCI评审抽查病历以住院病历最多占75%,共有20类病种,病种分布依次为手术、急诊、儿童、镇静、心血管等。结论HIMSS信息化建设为有效巩固JCI条款标准、提高医疗质量提供了可靠帮助。通过对电子病历信息化改造,组织培训、多部门联合督导,质控发现的JCI相关典型问题改善显著,归档病历质量得到了评审专家的认可,医院高分通过JCI复评。
Objective To discussion on the application value of HIMSS 7 informatization in the examination of JCI archived medical records.Methods Comparison of the fifth edition,the sixth edition of the"JCI Medical Record Review Form".The final quality control Medical Records for the period from January 2018 to January 2019 are derived in the"final quality control statistical report"of the hospital HIS medical record management system.Analysis of archived medical records of previous JCI review patient papers.Statistical analysis of data with Excel 2007 software.Results An increase of 10 items in the sixth edition of the"JCI Medical Record Review Form"as compared to the fifth edition of the general review section.Through the reform of information system,from January 2018 to January 2019,there was a significant decrease in the number of JCIrelated four types of typical problems.The medical records of all previous JCI reviews are up to 75%of the medical records in the hospital.There are 20 types of diseases.The distribution of the disease is the operation,the emergency,the child,the sedation,the cardiovascular and the like.Conclusion The construction of himss informatization provides reliable help for the effective consolidation of JCI terms and standards and the improvement of medical quality.Through the transformation of electronic medical records information,quality control found in the JCI-related typical problems improved significantly.The quality of archived medical records has been recognized by experts,and the hospital has a high score through JCI.
作者
吴玉连
许慧娜
卢介珍
WU Yulian;XU Huina;LU Jiezhen(Department of Medical Record,FirstAffiliated Hospital of Xiamen University,Xiamen Fujian 361003,China)
出处
《中国卫生标准管理》
2019年第18期1-4,共4页
China Health Standard Management
关键词
HIMSS7
信息化
JCI
复评
归档病历
病历审查
HIMSS 7
informatization
JCI
re-evaluation
file medicalrecords
medical record review
