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目的探索病案翻拍制作过程的质量管理方法,评价全程质量管理对数字化病案质量的影响。方法对病案翻拍数字化病案制作过程进行全程质量管理,包括建立数字化病案工程领导小组、建立新病案管理模式、规范病案翻拍数字化病案制作流程、培训工作人员、建立质检工作站、建立三级(翻拍人员、公司方、院方)质检反馈机制、建立病案领取、归还制度。评价比较进行全程质量管理前后数字化病案的质量变化。结果实施全程质量管理后总的质检合格率由94.7%提高到99.0%,P<0.01。结论实施全程质量管理可大大提高数字化病案质量,确保数字化病案的完整、准确、清晰,可最大限度地代表原始病案。
Objective To explore the method of quality management in the process of remake of medical records and to evaluate the effect of quality control on the quality of digital medical records. Methods The whole process of quality management of the digital medical record making process including the establishment of a digital medical record leading group, the establishment of a new medical record management model, the standardization of medical records remake of digital medical record making processes, training of staff, the establishment of quality control workstations, the establishment of three-level , The company side, hospital) quality inspection feedback mechanism, the establishment of medical record collection, return system. Evaluation of quality management before and after the comparison of the quality of digital medical records changes. Results After the implementation of total quality management, the total quality inspection pass rate increased from 94.7% to 99.0%, P <0.01. Conclusion The implementation of full quality management can greatly improve the quality of digital medical records to ensure that digital medical records are complete, accurate and clear, and can represent original medical records to the maximum extent.