运用信息化手段加强医疗质量环节中控制的体会

摘要

实时的环节中监控是医疗质量控制的关键，在信息化手段辅助下的医疗质控，更应强调可操作性。通过对电子病历时限和结构完整性要求、围手术期各项制度、危急值及时处理及规范记录、有创操作、高风险诊疗项目操作知情告知及规范记录等设定质量控制规则，集成化方式提供质控信息，建立有效质量控制信息反馈渠道，网络培训改变质控受众观念等一系列流程，最大限度发挥信息平台的严谨、实时、多样的特点，实现巩固和提高医疗质量的目的。%Real time process control is the key point of medical quality control. By the help of informatization methods, medical quality control needs to emphasis its implementation. By setting up quality control conditions which involve electronic medical record submission deadline and quality, perioperative period regulations, critical values timely intervention and standardized record, informed consent and standardized record on invasive manipulation and high risk manipulation, medical quality information can be integrated provided. By establishing effective quality control information feedback platform and website training to change conception, the strengths of information platform such as rigorous, real time and diverse are fully played to promote medical quality.