【作者】 凌勇武； 朱慧； 黄松平；

【Author】 Ling yongwu;Zhu hui;Huang songping;

【机构】 南通市第三人民医院医务科；

【摘要】 为更好地规范医师书写电子病历,我院将近年来在国际医院评价中出现的一种体现以病人为中心的追踪方法学(TM)理论及方法引入到电子病历质量持续改进管理中,结合具体案例,运用个案追踪和系统追踪的方法评判电子病历质量中存在的问题,制定持续改进方案,并建立长效管理机制,以减少缺陷病历发生,从而提高病案甲级率,促进医疗质量的提高,确保医疗安全。更多还原

【Abstract】 To regulate the physicians’ narratives of electronic medical records better,we applied the patient oriented tracer methodology theory which emerged in international hospital appraisal in current years to establish a Long-term management mechanism for quality management of electronic medical records.We judged existing problems in the process of evaluation of diagnosis and treatment on the basis of individual case and tracking system with specific cases.And then keep continuous improvement to reduce the defects of cases,Improve the medical grade rate,the quality of medical and guarantee safety of medical.更多还原