电子病历质量监控系统的功能与应用

摘要

目的：加强病历质控，提高病历质量，保障医疗安全。方法有效运用电子病历质控系统，对在院病历进行系统检查、环节实时分级控制、持续质量改进，对出院病历进行终末控制。结果病历及时性提高，雷同率降低，医院病历质量明显提高。结论利用电子病历质控系统，病历质量得到持续改进，病历完整性、正确性有了明显提高，保证病案医疗、教学、科研等服务水平。%Objective To strengthen the management, improve the quality of medical records, and ensure medical safety. Methods Effectively make use of the electronic medical record quality monitoring system to systematically check all the medical records, hierarchically real-time control every medical step, continuously improve quality and conduct terminal control on the leaving-hospital records. Results The timeliness of medical record is improved, the similarity rate is decreased, and consequently the quality of medical record is signiifcantly improved. Conclusion With electronic medical record quality monitoring system, the integrality and accuracy of medical records are improved signiifcantly, which lays a good foundation for medical care, teaching, research and other medical services.