摘要
目的分析某院在数字化转型进程中病案数据面临的质量风险,并采取应对措施,以提高病案数据质量。方法采用PDCA管理方法,对病案首页中患者的基本信息进行梳理与追踪分析,实施了包括流程再造、完善标准数据库与质控规则、建设病案数据指标可视化平台以及针对相关人员专业培训等改进措施。结果病案首页患者基本信息的完整性得到显著改善,数据缺失与错误现象大幅减少,病案首页的整体质量得到有效提升。结论通过信息采集流程同质化管理,系统设置智能校验机制,加强数据质量培训,建立多部门协助机制等措施,可以提升病案首页信息的完整性、准确性,提高医院管理水平。
Objective To analyze the quality risks faced by medical record data in the process of digital transformation in a hospital,and take countermeasures to improve the quality of medical record data.Methods PDCA closed-loop management method was used to sort out and track the basic information of patients in the medical record home page.Improvement measures including process reengineering,improvement of standard database and quality control rules,construction of medical record data index visualization platform and professional training for relevant personnel were implemented.Results The integrity of the basic information of patients on the medical record home page was significantly improved,and the phenomenon of data loss and error was greatly reduced.The overall quality of the medical record home page has been effectively improved.Conclusion Measures such as homogenization management of information collection process,intelligent verification mechanism of system setting,strengthening data quality training,and establishing multi-department assistance mechanism can improve the integrity and accuracy of the medical record home page and improve the level of hospital management.
作者
刘媛
汪刚
LIU Yuan;WANG Gang(Shanghai Chest Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai,200030,China;不详)
出处
《中国卫生质量管理》
2025年第2期38-41,共4页
Chinese Health Quality Management
基金
国家卫生健康委医院管理研究所2024年医疗质量(循证)管理研究重大项目(编号:YLZLXZ24H001)
上海申康医院发展中心市级医院诊疗技术推广及优化管理项目(编号:SHDC22024225)。
关键词
数字化转型
病案
PDCA
数据质量
Digital Transformation
Medical Record
PDCA
Data Quality
