【摘要】 目的探讨加强门诊病历质量管理的有效方法。方法医院信息系统开发"门诊病历网上实时监控系统",使门诊病历录入结构化,对每份病历自动评分和手工评分,并网上实时反馈病历缺陷。结果门诊病历网上实时监控系统实现了对每份病历均进行质控,使整改周期缩短至几小时,工作效率、门诊病历质量大幅度提高,合格率从53.8%上升到96.3%(P<0.01)。结论门诊病历网上实时监控系统对提高门诊病历质量发挥巨大作用,有推广价值。更多还原

【Abstract】 Objective: To explore the effective methods for enhancing quality management of outpatient medical re- cords. Method: The"online real-time monitoring system for outpatient medical records"in hospital information system is developed,w hich structuralizes the type-in of outpatient medical records,automatic grading and manual grading of each medical record,and makes online real-time feedback on medical record defects. Result: The online real-time monitoring system realizes quality control over each medical record,shortens rectification period to few hours,and improves w orking efficiency and the quality of outpatient medical records. The qualified rate increases from 35% to 96. 3% ( P < 0. 01) . Con- clusion: The online real-time monitoring system for outpatient medical records plays a huge role in the improvement of the quality of outpatient medical records,and it bears promotional value.更多还原