摘要
目的:探索使用数据元规范诊疗方案,实现医疗质量控制指标数据精准、自动采集。方法:制定医疗质量控制指标数据源体系,将医院评审标准内临床重点专业质量控制指标解析成数据元并部署在专病模板内,通过相关制度规范临床使用。结果:已经完成部署的12个相关专业的医疗质量控制指标数据元能够获取精准数据,促进医疗质量改进与提升。结论:将医疗质量控制指标数据元部署到各环节书写的医疗文书中,可实现数据精准、自动采集,实现质量控制指标对临床诊疗的规范和指导作用。
Objective To explore the use of data elements to standardize the diagnosis and treatment plan and to realize accurate and automatic data collection of medical quality control indexes.Methods By developing the data source system of medical quality control indexes,the quality control indexes of key clinical principles within the hospital evaluation standards were analyzed into data elements and then deployed in the special disease templates,and the clinical use was regulated by applying the relevant system.Results The deployed data elements of medical quality control indexes of 12 related specialties can obtain accurate data and promote the improvement of medical quality.Conclusion The data element of medical quality control index deployed in the medical documents written in each link can achieve accurate and automatic data collection and realize the role of quality control indexes in regulating and guiding clinical diagnosis and treatment.
作者
杨森
刘崇华
胡杰
冉茂波
朱小凤
YANG Sen;LIU Chonghua;HU Jie;RAN Maobo;ZHU Xiaofeng(Suining Central Hospital,Suining 629000,Sichuan Province,China;Sichuan Vocational and Technical College)
出处
《中国数字医学》
2023年第7期76-80,共5页
China Digital Medicine
基金
四川省基层卫生事业发展研究中心项目-基于社会网络的慢性病患者基层就医行为研究(SWFZ19-Y-49)。
关键词
医疗质量
指标体系
数据元
信息化建设
Medical quality
Index system
Data element
Information construction
