病历质量评价流程信息化改造及效果评价

摘要

目的:促进病历质量评价方便快捷.方法:制定标准,对病历质量评价流程进行信息化改造.结果:实现了通过病历自动筛选及匹配、病历资料在线阅览与评分、考核结果自动生成、数据统计自动分析.结论:病历质量评价流程信息化让整个流程更顺畅、便捷、公正和高效,能进一步提高病历书写质量和病案管理水平,促进病历书写质量和病案管理质量的持续改进与发展.%Objective:Making medical quality evaluation more convenient and quickly.Methods:Making standards for information transformation of medical record quality evaluation process.Results:Realizing the automatic terminal medical screening and matching,medical records online reading,assessment results automatically generating,statistical data automaticallyanalyzing.Conclusion:Through the information transformation process of terminal medical record quality evaluation,the whole process of the terminal medical record quality evaluation become more smoothly,more convenient,fairer,more efficient finally.So as to further improve the quality of medical records and medical record management level,promote the continuous improvement and development of the quality of medical records and medical record quality management.