一种基于电子病历的首页审核模式介绍

摘要

This paper introduces a kind of electronic medical record front sheet audit mode. The model under the background of electronic medical record system construction,adhere to the principle of the international classification of diseases "coding dominant", classification of diagnosis and clinical diagnosis of seeking common ground while putting aside differences",medical record management personnel and medical staff good communication and interaction, review process step-by-step", the multi-level, multi-angle training on the basis of the step by step. This mode optimize the medical record management and clinical departments work flow, promotes the medical record management idea transformation, promote the construction of the hospital information system, improve the working efficiency, has obtained the good effect.%本文介绍了我院的一种电子病历首页审核模式。该模式在医院电子病历系统建设背景下，坚持国际疾病分类“编码主导”、分类诊断与临床诊断“求同存异”、病案管理人员与医护人员良好“沟通互动”、审核过程“分步实施”为原则，并在多层次、多角度培训的基础上得以循序渐进地进行。模式的实施优化了病案管理与临床科室工作流程，促进了全院病案管理理念转变，推动了医院信息系统建设，提高了工作效率，取得了良好效果。