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目的针对目前电子病历内涵质控面临的问题,探讨提高电子病历内涵质量的实践和效果。方法借助信息化评审平台,组建病历评审专家组,建立电子病历内涵质量评审机制。结果通过一年的具体实践,在术前讨论记录、手术记录、首次病程记录、上级医师查房记录、出院记录的内涵质量均得到全面提升。结论利用专家评审病历内涵质量的形式,对提高病历内涵质量起到积极作用。
Objective To address the current problems in the content control of electronic medical records, and to explore the practices and effects of improving the quality of electronic medical records. Methods With the help of informatization evaluation platform, a group of medical record review experts was set up to establish the quality review mechanism of electronic medical record connotation. Results Through the practice of one year, the quality of connotation of preoperative discussion and record, surgical record, first course record, superior physician ward rounding record and discharge record were all improved. Conclusion The use of expert assessment of the quality of medical records in the form of content, to improve the quality of medical records play a positive role.