摘要
病案管理是医院管理的重要组成部分。当前病案管理存在病案归档情况掌握不及时、病案完成情况评价困难、病案管理工作效率亟待提升等问题。通过信息系统建设,实现病案室全业务流程无纸化,形成病案签署及质控闭环、病案流通闭环、病案全生命周期示踪管理闭环,建立了医师病案完成评价体系、质控效率评价体系、带教能力评价体系,有效提升了医院的管理水平。
Medical record management is an important part of hospital management. Difficult to obtain medical record archiving information, difficult to evaluate completion, low efficiency are current drawbacks for medical record management. The realization of medical record room by developing information system. Sign and quality control closed-loop, case circulation closed-loop, and full life cycle tracer closed-loop were formed. The medical record completion evaluation system, quality control efficiency evaluation system and teaching ability evaluation system were established. This work raises the level of medical record management.
作者
孙晋科
王晓盈
姜国成
SUN Jin- ke;WANG Xiao-ying;JIANG Guo-cheng(The 202 Military Hospital of China, Shenyang 100082, Liaoning Province, P.R.C.)
出处
《中国数字医学》
2018年第6期110-112,共3页
China Digital Medicine
关键词
病案管理
无纸化
归档
闭环
medical record management
paperless
archiving
closed-loop
作者简介
通讯作者：姜国成
