军队医院病案首页网络质控的实践

发布时间：2018-01-02 09:14

本文关键词：军队医院病案首页网络质控的实践　出处：《中国病案》2016年01期 　论文类型：期刊论文

【摘要】：目的探索解决病案延期归档或无纸化时病案首页质控问题。方法依靠现有平台,采用C/S架构设计,采用DELPHI开发工具开发的病案管理系统可以实现军队医院首页网络质控。结果编目的同时进行病案首页质控,保证时效性,人工核查与计算机智能核查保证准确性,并利用系统自动登记病案首页质控,为千分考核提供依据。结论病案管理系统实现编目员在线编码、网络质控,确保病案首页质量准确性,提高了工作效率,解决了病案无纸化进程中的一大难题。病案无纸化推动传统病案管理模式的不断创新与持续改进。病案管理流程与相关配套软件要配合无纸化进程不断优化。
[Abstract]:Objective to explore how to solve the problem of quality control of the first page of medical records when medical records are delayed archiving or paperless. Methods based on the existing platform, the C / S structure is used to design the medical records. The medical record management system developed with the DELPHI development tool can realize the network quality control of the front page of the military hospital. Results the quality control of the first page of the medical record can be carried out at the same time as cataloguing to ensure the timeliness. Manual verification and intelligent computer verification ensure the accuracy and use the system to automatically register the first page of medical records quality control to provide a basis for thousands of points. Conclusion the medical records management system to achieve online cataloguer coding network quality control. Ensure the quality and accuracy of the first page of the medical record, and improve the working efficiency. The paper solves a difficult problem in the paperless process of medical record. It promotes the innovation and continuous improvement of the traditional medical record management mode. The process of medical record management and related supporting software should be optimized continuously with the paperless process.
【作者单位】：解放军第174医院信息科;
【分类号】：R82
【正文快照】： 电子病历是信息技术和网络技术在医疗领域的必然产物,是医院病历现代化管理的必然趋势,也是建设数字化医院的基础,是医院进入信息化社会的重要桥梁[1]。随着医疗信息化技术的不断发展,电子病历的无纸化管理,已经成为各医院的研究热点。无纸化电子病案的实施,将以其独特的科学

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