病历书写时限质量在线控制系统的研究与应用.docxVIP

病历书写时限质量在线控制系统的研究与应用 作者： [摘要]目的建立和应用病历书写时限质量在线控制系统，以期能够准确评价 和严格控制病历书写的时限质量。方法 根据《病历书写基本规范》对病历书写 时限的规定，应用计算机技术采集、加工、传输和存储病历书写过程的实时信息， 建立时限质量在线控制指标体系，设计时限质量在线控制系统。结果 在我院 34个科室的应用实践表明，该系统成功地实现了监控、预警、反馈、评分和智 能判别五大功能。结论 该控制系统的建立和应用，对加强医疗环节质量管理， 规范医疗行为，降低医疗缺陷，提高医疗质量起到了十分有效的作用。 [关键词]病史记录；书写；病案系统；计算机化；质量控制 The research and application of Quality Control Online System of Time Limit in Patient Record Writing WU Wei-bin*,XIAO qiang,CHEN lian-zhong,et al. ^Guangzhou General Hospital of Guangzhou Military Command, Guangzhou 510010, China [Abstract] Objective Quality Control Online System of Time Limit in Patient Record Writing was developed and taken into practice to evaluate accurately and control strictly of time limit quality in patient record(PC) writing. Methods Based on 《fundamental specification in patient record writing》，the collection, processing, transmission and storage of real-time information during PC writing were realized by computer techniques, time limit quality control indexes were set up, quality control online system was designed. Results Being used in 34 clinical departments in our hospital, the system has been identified to realized five functions successfully which are supervision and control, forewarning, feedback, scoring and intellectual judgement. Conclusion This control system is very effective for enhancing medical linkage quality management, restraining medical behavior, correcting medical defect and improving medical quality. [Key words] Medical history taking; Handwriting; Medical records systems; Computerized; Quality control 病历书写吋限是指完成病历书写内容所规定的吋间范围。评价病历书写及吋与 否的根本依据是时限质量，这也是评价病历书写质量的关键内容Z—。长期以來， 由于在病历质量评价中所获得的信息大都是“时间延滞” (timelag)信息，故对病 历书写的时限质量评价是不准确的，这成了病历质量控制一直难以解决的问题。 我们应用计算机技术釆集、加工、传输和存储病历书写过程的实时信息，探索病 历书写时限质量在线控制的方法，强化医疗质量管理，辅助临床医师防范医疗缺 陷，有效地提高了医疗环节质量。 一、《病历书写基本规范》对病历书写时限的规定 卫生部、国家中医药管理局颁布的《病历书写基木规范》(以下简称《规范》) |1|，对病历书写时限在16个方面作了明确的规定： 入院记录、再次或多次入院记录应当于患者入院后24小时内完成；24小时 内入岀院记录应当于患者岀院后24小时内完成；24小时内入院死亡记录应当于 患者死广后24小时内完成。 首次病程记录应当在患者入院8小时内完