基于电子病历系统的临床医疗质量实时控制

摘要

The paper explored the online real-time system built at the hospital to monitor clinical care quality using EMR.The methodology,procedures and index system were established for real-time clinical care quality control.With the online control in place,significant improvements were found in such care indexes as implementation of essential healthcare regulations,EMR quality,rational drug use and rational blood use,making quality control much efficient than before.EMR-based online clinical care quality control can improve quality of care,make it efficient and guide clinical care and quality control as well.%对医院建立基于电子病历系统的临床医疗质量在线实时监控系统进行了探讨,建立了临床医疗质量实时控制方法、程序和指标体系.实施在线控制后,医疗核心制度落实、电子病历质量、合理用药和合理用血等医疗质量指标均明显改善,质量控制效率明显提高.基于电子病历系统的临床医疗质量在线实时控制,能够改善医疗质量,提高医疗质量控制效率,并对临床医疗和质量控制具有现实指导作用.