摘要
为助力国家医院信息互联互通标准化成熟度测评工作,进一步规范医院病历数据应用及管理,2021年4月起某医院开展了以提升病历数据质量为目标的电子病历结构化设计及质量管理实践。医院基于六西格玛质量管理方法与理念,制定了电子病历通用模板和候选电子病历模板名单,分析了病历数据面临的问题,从模板设计、软件功能及管理服务3个层面提出改进策略,引导临床科室设计并开发专科和专病等各类电子病历的结构化模板,建立了病历模板设计与质量管理办法。该实践累计设计出614份符合医院实际的结构化电子病历模板,不仅增强了结构化病历模板扩展性,提高了病历数据质量,还确保医院在满足信息互联互通的同时实现病历模板的本地化与专科化,为进一步推动我国医院电子病历的互联互通共享提供参考。
In order to assist in the standardization and maturity evaluation of national hospital information interconnection,and further standardize the application and management of hospital medical record data,a hospital carried out the practice of design of structured medical records and the corresponding quality management from April 2021.Based on the six sigma quality management method,the hospital had developed universal templates for electronic medical records and a list of candidate electronic medical record templates.The problems faced by medical record data had been analyzed,and improvement strategies had been proposed from three levels:template design,software functionality and management services.The clinical departments were guided to design and develop various structured electronic medical record templates for specialties and specialized diseases,and established a medical record template design and quality management method.The hospital had ultimately designed a total of 614 structured electronic medical record templates that met the actual needs of the hospital.This practice enhanced the scalability of structured templates and quality of the data,and achieved localization and specialization of medical record templates while meeting the requirements of information interconnection and sharing,providing reference for promoting the interconnection and sharing of electronic medical records of hospitals in China.
作者
梅甜
佘广南
赵云龙
周邮
赵雨
伊永菊
Mei Tian;She Guangnan;Zhao Yunlong;Zhou You;Zhao Yu;Yi Yongju(Department of Information and Data,the Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China;Department of Medical Administration,the Sixth Affiliated Hospital,Sun Yat-sen University,Guangzhou 510655,China)
出处
《中华医院管理杂志》
CSCD
北大核心
2023年第5期347-351,共5页
Chinese Journal of Hospital Administration
基金
广州市重点研发计划(SL2022B03J00982)。
关键词
电子病历
结构化设计
互联互通
质量管理
数据治理
Electronic medical record
Structured design
Interconnection
Quality management
Data governance
