基于电子病历的病案质量实时控制实践

摘要

电子病历的广泛应用,实现了病案质量管理从专家审核到计算机自动控制阶段的过渡.从病案质量的时限控制、依赖控制、数量控制、智能提醒等4个方面,论述了目前电子病历存在的问题及解决的措施,实现了病案质控工作从“事后把关”到“过程管理”的转变,提升了病案管理水平.%Electronic Medical Record System has been widely adopted,which make medical record quality management developed from expert-audit into computer automatic control stage.Problems and related resolutions were discussed from four aspects of deadline control,sequence control,missing item control,and intelligent awake system.By the transformation from afterwards audit to process control,the management level of medical records was improved.