病历书写时限质量在线控制系统的研究与应用.doc

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 \o "医星质量管理系统" 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 \o "医星质量管理系统" 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 \o "医星质量管理系统" 质量在线控制指标体系，设计时限 \o "医星质量管理系统" 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 \o "医星质量管理系统" 质量管理，规范医疗行为，降低医疗缺陷，提高医疗 \o "医星质量管理系统" 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； \o "医星质量管理系统" 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 　　病历书写时限是指完成病历书写内容所规定的时间范围。评价病历书写及时与否的根本依据是时限 \o "医星质量管理系统" 质量，这也是评价病历书写 \o "医星质量管理系统" 质量的关键内容之一。长期以来，由于在病历 \o "医星质量管理系统" 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 \o "医星质量管理系统" 质量评价是不准确的，这成了病历 \o "医星质量管理系统" 质量控制一直难以解决的问题。我们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，探索病历书写时限 \o "医星质量管理系统" 质量在线控制的方法，强化医疗 \o "医星质量管理系统"