Objective: Inpatient medical records is access to electronic medical records, summary index application, so the quality of hospital medical records determines the entire medical records. Methods: The development of multiple tables automatic correlation analysis, logic procedures to ensure the continuity of data upload, timeliness, completeness and correctness based on inpatient medical records. Results: In three comprehensive hospital pilot, currently, electronic medical records clean upload reached 36080 copies, a 45 percent increase compared to the past, the error correction rate of 20% over the pilot results. Conclusion: The data quantity and quality has improved significantly by the establishment of data quality control mechanisms, and the combination of procedures and artificial, and combined the terminal quality control and each link quality control.%目的:住院病案首页是电子病历调阅、应用的概要索引,因此病案首页质量如何,关系整个病历质量的优劣.方法:以病案首页为核心,开发多个表的自动关联性分析、逻辑判断程序,确保数据上传的连续性、及时性、完整性与正确性.结果:通过在三家综合型医院进行试点,目前电子病历清洗上传量达到36080份,较过去提升45%,纠错率提高20%,效果理想.结论:通过建立数据质控机制,程序与人工相结合,终末质控与环节质控相结合,数据数量与质量都有明显提升.
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