CN114743624A - Quality control management method and system for electronic medical records of outpatient (urgent) clinic - Google Patents
Quality control management method and system for electronic medical records of outpatient (urgent) clinic Download PDFInfo
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Abstract
The invention discloses a quality control management method and a system for an electronic medical record of an outpatient (emergency) clinic. The method comprises the following steps: setting quality control and management rules of the electronic medical record for the outpatient (emergency) diagnosis; performing quality control management on the electronic medical record for clinic (emergency) diagnosis according to the quality control and management rules; and obtaining the quality control result of the electronic medical record of the department (emergency) examination, making a quality control management report, and performing performance evaluation and quality control feedback. The system comprises: the system comprises a rule setting unit, a process management unit, a post management unit and a permission management unit. The invention can effectively carry out quality control management on the electronic medical records for the outpatient (emergency) examination, improve the quality of the electronic medical records for the outpatient (emergency) examination, improve the quality control efficiency of the electronic medical records for the outpatient (emergency) examination and realize the quality control performance management of the electronic medical records for the outpatient (emergency) examination.
Description
Technical Field
The invention relates to the technical field of medical services, in particular to a quality control management method and system for an electronic medical record of an outpatient (emergency) clinic.
Background
The statements in this section merely provide background information related to the present disclosure and may not constitute prior art.
The medical record refers to the sum of characters, symbols, diagrams, images and other data formed by medical staff during medical activities, and includes an outpatient (emergency) medical record and an inpatient medical record. Most medical institutions are strict in quality control management of in-patient medical records, and often neglect quality control management of out-patient (emergency) medical records. The clinic (emergency) medical record is also used as an information carrier of medical activities and has medical and legal values. Strengthening the quality control management of the clinic (emergency) medical record has important significance for standardizing clinic medical behaviors, improving medical services and improving medical quality.
With the continuous promotion of national health and defense committee to the development of hierarchical evaluation work of application levels of electronic medical records in national medical institutions, all medical institutions establish outpatient (emergency) electronic medical record systems, but the quality control management of the outpatient (emergency) electronic medical records has great limitation, the outpatient (emergency) electronic medical records are usually required to be completed within a few minutes, the quality control is lack of systematic, automatic and intelligent mechanisms, and the management is difficult. At present, the quality control work of outpatient medical records is mainly carried out by manual spot check by relevant departments of hospitals, the manual spot check result is difficult to cover comprehensively, the subjective factor influence is large, the condition of the medical records in the whole hospital cannot be reflected comprehensively, the efficiency is low, and the quality control effect is poor.
Disclosure of Invention
In order to solve the defects of the prior art, the invention provides a quality control management method and a system for an outpatient (emergency) electronic medical record, which can effectively perform quality control and management on the outpatient (emergency) electronic medical record, improve the quality of the outpatient (emergency) electronic medical record, improve the quality control efficiency of the outpatient (emergency) electronic medical record and realize the quality control performance management of the outpatient (emergency) electronic medical record.
In a first aspect, the invention provides a quality control management method for an electronic medical record of an outpatient (emergency) clinic, which is characterized by comprising the following steps:
setting quality control and management rules of the electronic medical record for the outpatient (emergency) diagnosis;
performing quality control management on the electronic medical record for outpatient (urgent) diagnosis according to the quality control and management rules;
and obtaining the quality control result of the electronic medical record of the outpatient (urgent) diagnosis, making a quality control management report, and performing performance evaluation and quality control feedback.
Furthermore, the quality control and management rules are set according to the application level grading evaluation criteria (trial) of the electronic medical record system, the basic specifications of writing and managing medical records in Shandong province and the related management regulations of medical records in hospitals; the quality control rules comprise an integrity quality control rule, a logic quality control rule, a time limit quality control rule, a context content quality control rule and the like; the management rules comprise doctor operation and authority management, medical record printing and filing management, quality control personnel authority management, medical record quality control performance management and the like.
Further, the quality control management of the electronic medical record for outpatient (emergency) diagnosis comprises the following steps:
process management, namely performing in-situ real-time monitoring and management on the process of writing medical records by a doctor and simultaneously recording all operations of the doctor; post management, namely performing printing management, filing management, post quality control management of medical records, various statistical queries, performance association and other management on the medical records;
and (4) authority management, namely managing various medical record operation authorities (such as retrieval authority, reference authority, modification authority, quality control authority and the like) of doctors and quality control personnel.
In a second aspect, the present invention provides an out-patient (emergency) electronic medical record quality control management system, including:
the rule setting unit is used for setting quality control and management rules of the electronic medical record for outpatient (urgent) diagnosis;
the process management unit is used for real-time quality control and management in the process of writing medical records by doctors and simultaneously recording all medical record operations of the doctors;
the post management unit is used for performing management such as printing management, filing management, post quality control management, various statistical queries, performance association and the like on the medical records;
and the authority management unit is used for managing various medical record operation authorities (such as retrieval authority, reference authority, modification authority, quality control authority and the like) of doctors and quality control personnel.
Further, the process management unit includes:
the process quality control module is used for automatically controlling the quality of medical records according to medical record quality assessment indexes (such as completeness, logicality, timeliness and context content examination) in the writing process of the electronic medical records of the outpatient (emergency) service;
and the operation trace-remaining module is used for acquiring all operations of a doctor in the process of writing a medical record and displaying trace-remaining.
Further, the process quality control module comprises:
integrity quality control, which is used for carrying out integrity judgment on each paragraph of the outpatient (urgent) diagnosis electronic medical record according to the medical record integrity quality control rule and carrying out word number limitation on a specific paragraph; for medical records with severe defects (such as a certain paragraph is not written or filled but the number of words is insufficient), quality control reminding is given to a doctor when the medical records are stored and/or signed;
the logic quality control is used for reminding in real time of obvious logic errors in the medical record writing process according to the logic quality control rule, such as site inconsistency, gender inconsistency and the like;
the time limit property control is used for reminding the problems of time limit exceeding and time effect exceeding in the medical record writing process in real time according to the time limit property control rule;
and the quality control of the context content is realized, and the writing content is intelligently checked and prompted by utilizing the medical knowledge graph according to the medical record context content.
Further, the post management unit includes:
the medical record printing management module is used for limiting printing of medical records with serious defects, and the medical record printing permission is limited to that a doctor can not print the medical records, the outpatient department can print the medical records infinitely, and a self-service machine can print the medical records in limited number of copies;
the case history filing management module is used for automatically realizing PDF filing on a filing server after the zero point of the next day for all the door (emergency) diagnosis electronic case histories which are written and signed;
the post quality control module is used for performing quality control on the medical record according to the quality assessment indexes of the medical record after the electronic medical record is subjected to outpatient (emergency) diagnosis and obtaining a post quality control result;
and the statistical management module is used for retrieving medical records, performing statistical query on various reports and butting the reports so as to meet the management requirements of doctors on statistical query, scientific research and quality control and performance of management departments and the like.
Further, the post quality control module comprises:
the automatic quality control sub-module is used for automatically grading according to quality control rules such as the completeness, the logic, the timeliness and the like of the electronic medical record of the clinic (emergency) diagnosis, and automatically confirming the quality grade (grade A, grade B or grade C) of the medical record according to the grading to obtain a post quality control result; and the manual quality control sub-module is used for performing manual quality control management on the medical records by quality control personnel, selecting corresponding quality control items according to medical record problems on the basis of automatic quality control, manually grading each quality control item corresponding to a corresponding score, and automatically confirming the quality grade of the medical records according to the grading to obtain a post quality control result.
Further, the manual quality control submodule comprises:
random spot check and quality control, wherein quality control personnel can randomly spot check any number of medical records in a certain period of time, and the random spot check comprises various modes such as hospital random spot check, department random spot check, physician random spot check and the like;
and (4) specifying quality control, namely performing medical record quality control through conditions such as a specified time period, an institution, a department, a doctor, a title and/or a patient.
Further, the post-affair quality control result can be fed back to a department owner and/or a medical record writing doctor at a designated time through a Hospital Information System (HIS) message platform or an enterprise WeChat message.
Further, the statistics management module includes:
the medical record retrieval submodule is used for arbitrarily customizing the content of the condition combined retrieval gate (emergency) diagnosis electronic medical record, can customize an arbitrary time period and arbitrary structured project combination combined retrieval, and can also customize a retrieval result list, and the retrieval result is subjected to data desensitization to meet the retrieval requirement of any medical record;
the statistical query submodule is used for counting the writing condition, the quality control condition, the modification and approval condition and the like of medical records of departments, areas and/or whole hospitals in any time period;
and the report docking sub-module is used for making a quality control report and a performance report according to the writing condition of the department and the personal writing condition of the doctor, and performing data docking with a Hospital Information System (HIS) message platform, an enterprise WeChat, a hospital performance evaluation system and/or a hospital comprehensive office system.
Further, the rights management unit includes:
the retrieval authority management module is used for managing and controlling the authority of a doctor for retrieving the medical record information of the patient, and limits that the doctor can only retrieve and see all the medical record information of the patient in the whole life cycle of the hospital, including the medical record of the current (urgent) examination, the medical record of the patient in the hospital, the physical examination record, the examination result, the vital sign record and the like;
the quotation authority management module is used for the authority control of the doctor for quotation of the medical record information of the patient, and limits that the doctor can only quote partial contents of all medical record information of the patient to be treated in the whole life cycle of the hospital and can not quote any medical record information of other patients; the modification authority management module is used for controlling the modification authority of the electronic medical record for the doctor in the department of emergency treatment, the medical record modification authority is limited after the medical record is printed, and the modification authority needs to be applied and examined and approved;
and the quality control authority management module is used for controlling the post-affair quality control authority of the electronic medical record for the outpatient (emergency) examination and setting three-level management authorities of department quality control, outpatient department quality control and medical record department quality control.
Furthermore, the modification authority management module is used for respectively managing the outpatient and the emergency patients; the outpatient needs to judge whether the patient is on the current date of the clinic, if so, the doctor applies for the modification right and then automatically checks, and the medical record can be modified in real time; if not, the doctor can modify the medical record only after the doctor applies for the modification authority and needs to be audited by an outpatient department; the emergency patient does not need to judge the patient's date of seeing a doctor, and the doctor can revise the case history in real time after applying for the revision authority and automatically audits.
Furthermore, the quality control authority management module sets three levels of management authorities of department quality control, outpatient department quality control and case department quality control. The department quality control designates quality control personnel by the department, and the authority is set to view and quality control the electronic medical record of the (emergency) diagnosis of the department room door; the outpatient department quality control is realized by the outpatient department quality control personnel through the quality control and management of the electronic medical records of the whole hospital (emergency) clinic; the quality control of the medical record department is carried out by the quality control personnel of the medical record department on the quality control and management of the outpatient (emergency) medical record after the whole hospital is filed.
Compared with the prior art, the system and the method have the advantages that the electronic medical records for the outpatient (emergency) examination are comprehensively controlled and managed, the operation of the outpatient (emergency) examination doctor is standardized, the quality of the electronic medical records for the outpatient (emergency) examination is improved, the quality control efficiency of the electronic medical records for the outpatient (emergency) examination is improved, and the quality control performance management of the electronic medical records for the outpatient (emergency) examination is realized.
Advantages of additional aspects of the invention will be set forth in part in the description which follows, or may be learned by practice of the invention.
Drawings
The accompanying drawings, which are incorporated in and constitute a part of this specification, are included to provide a further understanding of the invention, and are incorporated in and constitute a part of this specification, illustrate exemplary embodiments of the invention and together with the description serve to explain the invention and not to limit the invention.
FIG. 1 is a flow chart of the method for quality control management of an electronic medical record for outpatient (emergency) diagnosis according to the present invention;
FIG. 2 is a functional block diagram of the quality control system for the electronic medical records of the department of outpatient service (emergency) according to the present invention;
FIG. 3 is a functional block diagram of a process management unit in the quality control management system for the outpatient (emergency) medical records according to the present invention;
FIG. 4 is a functional block diagram of a post-event management unit in the quality control management system for the outpatient (emergency) medical records according to the present invention;
FIG. 5 is a functional block diagram of an authority management unit in the quality control management system for outpatient (emergency) medical records according to the present invention.
Detailed Description
It should be noted that the following detailed description is exemplary and is intended to provide further explanation of the invention. Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs.
It is noted that the terminology used herein is for the purpose of describing particular embodiments only and is not intended to be limiting of exemplary embodiments according to the invention. As used herein, the singular forms "a", "an", and "the" are intended to include the plural forms as well, unless the context clearly indicates otherwise, and it should be understood that the terms "comprises" and "comprising", and any variation thereof, are intended to cover a non-exclusive inclusion, such that a process, method, system, article, or apparatus that comprises a list of steps or elements is not necessarily limited to those steps or elements expressly listed, but may include other steps or elements not expressly listed or inherent to such process, method, article, or apparatus.
The embodiments and features of the embodiments of the present invention may be combined with each other without conflict.
All data are obtained according to the embodiment and are legally applied on the data on the basis of compliance with laws and regulations and user consent.
Example one
The embodiment provides a quality control management method for an electronic medical record of an outpatient (emergency) clinic.
A quality control management method for an outpatient (emergency) electronic medical record, as shown in fig. 1, comprising:
s01, setting quality control and management rules of the electronic medical record of the outpatient (emergency) clinic;
s02, performing quality control management of the electronic medical record of the clinic (emergency) doctor according to the quality control and management rules;
and S03, obtaining the quality control result of the electronic medical record of the department (emergency) examination, making a quality control management report, and performing performance evaluation and quality control feedback.
Furthermore, the quality control and management rules are set according to the application level grading evaluation criteria (trial) of the electronic medical record system, the basic specifications of writing and managing medical records in Shandong province and the related management regulations of medical records in hospitals; the quality control rules comprise an integrity quality control rule, a logic quality control rule, a time limit quality control rule, a context content quality control rule and the like; the management rules comprise doctor operation and authority management, medical record printing and filing management, quality control personnel authority management, medical record quality control performance management and the like.
Illustratively, the integrity quality control rule is used for carrying out integrity judgment on various sections (such as chief complaints, current medical history, past history, epidemiological history, physical examination, auxiliary examination, diagnosis and treatment plan, doctor signature and the like) of the electronic medical record of the department (emergency) diagnosis, and carrying out word number limitation on specific sections (such as chief complaints, current medical history and the like); for example: the medical record of the initial diagnosis requires: the chief complaints are not less than 4 characters or 2 Chinese characters, the current medical history is not less than 4 characters or 2 Chinese characters, and the prior history, epidemiological history, diagnosis and treatment plan, signature and the like are all null; the requirements of the medical record of the re-diagnosis: the chief complaints are not less than 4 characters or 2 Chinese characters, the medical history is not less than 4 characters or 2 Chinese characters, and the epidemiological history, diagnosis and treatment plan, signature and the like are all null; medical record requirements such as operation record, operation record and disease course record are as follows: recorded content and signatures are not empty.
Illustratively, the logic quality control rule carries out real-time quality control reminding on obvious logic errors occurring in the writing process of the medical record, if the parts are inconsistent, the right side is written in the chief complaint, and the left side occurs in the current medical history; or the sex is not consistent, the basic information of the patient is female, the testis appears in the medical record, or the basic information of the patient is male, the content of the uterus appears in the medical record, and the like, and the automatic reminding is carried out when the doctor saves or signs.
Illustratively, the time-limited quality control rule reminds the problems of time limit exceeding and time effect exceeding in the medical record writing process in real time; such as: the physician carries out time limitation on the (emergency) clinical false proof of the patient, for example, the limited time of the clinical false proof of the patient is generally not more than 7 days, the examination is required in special cases but not more than 1 month, and the limited time of the clinical false proof of the patient is not more than 3 days; and performing overtime effect reminding when the writing is less than 2 times within 24 hours of recording the emergency course.
Illustratively, the context content quality control rule intelligently checks and prompts writing contents by utilizing a medical knowledge graph according to medical record context contents; prompting suspected diagnosis according to written contents such as chief complaints, medical history and the like; and prompting possible diagnosis and treatment plans according to the chief complaints and the diagnosis.
Further, the quality control management of the outpatient (emergency) electronic medical record comprises the following steps:
process management, namely performing in-situ real-time monitoring and management on the process of writing medical records by a doctor and simultaneously recording all operations of the doctor; post management, namely performing printing management, filing management, post quality control management of medical records, various statistical queries, performance association and other management on the medical records;
and (4) authority management, namely managing various medical record operation authorities (such as retrieval authority, reference authority, modification authority, quality control authority and the like) of doctors and quality control personnel.
Illustratively, the quality control management report is in data interface with a Hospital Information System (HIS) message platform, an enterprise WeChat, a hospital performance evaluation system and/or department and doctor of the whole hospital, and comprises a quality control report and a performance report of the department and the doctor; the quality control report can be fed back to a department master or a medical record writing doctor at a designated time (monthly, next day or immediately) through a Hospital Information System (HIS) message platform or an enterprise WeChat message; the hospital performance department gives performance rewards or punishments according to the writing quality of the medical record of the medical staff in the performance report, and brings the writing rate of the department into the comprehensive objective assessment of the department; and quality control management departments (such as an outpatient department) report the writing condition of medical records of each department and doctors in a hospital comprehensive office system every month, and the departments and doctors with the medical record writing rate of less than 80% carry out hospital-wide report.
The invention standardizes the operation of the outpatient (emergency) doctor, improves the quality of the outpatient (emergency) electronic medical record, improves the quality control efficiency of the outpatient (emergency) electronic medical record and realizes the quality control performance management of the outpatient (emergency) electronic medical record by comprehensively controlling and managing the outpatient (emergency) electronic medical record.
Example two
The embodiment provides a quality control management system for an electronic medical record of an outpatient (emergency) clinic.
An outpatient (emergency) electronic medical record quality control management system, as shown in fig. 2, includes:
a rule setting unit 1 for setting quality control and management rules of an electronic medical record for outpatient (emergency) diagnosis;
the process management unit 2 is used for real-time quality control and management in the process of writing medical records by doctors and simultaneously recording all medical record operations of the doctors;
a post-event management unit 3, which is used for performing management such as printing management, filing management, post-event quality control management, various statistical queries and performance association on medical records;
and the authority management unit 4 is used for managing various medical record operation authorities (such as retrieval authority, reference authority, modification authority, quality control authority and the like) of doctors and quality control personnel.
Further, the process management unit 2, as shown in fig. 3, includes:
the process quality control module 21 is used for automatically controlling the quality of medical records according to medical record quality assessment indexes (such as completeness, logicality, timeliness and contextual content examination) in the writing process of the outpatient (emergency) electronic medical records;
the operation trace keeping module 22 is used for acquiring all operations (such as adding, modifying, storing, deleting and the like) in the process of writing the medical record by the doctor, and displaying trace keeping, and displaying a modifier, modifying time, modifying content and modifying a computer IP address.
Further, the process control module 21 includes:
integrity quality control, which is used for carrying out integrity judgment on each paragraph of the outpatient (emergency) medical record according to the medical record integrity quality control rule and carrying out word number limitation on a specific paragraph; for medical records with severe defects (such as a certain paragraph is not written or filled but the number of words is insufficient), quality control reminding is given to a doctor when the medical records are stored and/or signed;
the logic quality control is used for reminding the obvious logic errors in the medical record writing process in real time according to the logic quality control rule, such as site inconsistency, gender inconsistency and the like;
the time limit property control is used for reminding the problems of time limit exceeding and time effect exceeding in the medical record writing process in real time according to the time limit property control rule;
and the quality control of the context content is realized, and the writing content is intelligently checked and prompted by utilizing the medical knowledge graph according to the medical record context content.
Illustratively, the integrity control is used for carrying out integrity judgment on various sections (such as chief complaints, current medical history, past history, epidemiological history, physical examination, auxiliary examination, diagnosis and treatment plan, doctor signature and the like) of the electronic medical record for clinic (emergency) diagnosis according to medical record integrity control rules, and carrying out word number limitation on specific sections (such as chief complaints, current medical history and the like); for example: the requirement of initial medical record: the chief complaints are not less than 4 characters or 2 Chinese characters, the current medical history is not less than 4 characters or 2 Chinese characters, and the prior history, epidemiological history, diagnosis and treatment plan, signature and the like are all null; the medical record of the return visit requires: the chief complaints are not less than 4 characters or 2 Chinese characters, the medical history is not less than 4 characters or 2 Chinese characters, and the epidemiological history, diagnosis and treatment plan, signature and the like are all null; medical record requirements such as operation record, operation record and disease course record are as follows: the recorded content and the signature are not equal.
Illustratively, the logical quality control reminds an obvious logical error in the medical record writing process in real time according to the logical quality control rule of the medical record, if the part is not consistent, the right side is written in the chief complaint, and the left side is shown in the current medical history; or the sex is not consistent, the basic information of the patient is female, the testis appears in the medical record, or the basic information of the patient is male, the content of the uterus appears in the medical record, and the like, and the automatic reminding is carried out when the doctor saves or signs.
Exemplarily, the time limit property control reminds the problems of time limit exceeding and time effect exceeding in the medical record writing process in real time according to a time limit property control rule; such as: the physician gives the patient a (urgent) clinical hypothesis for time limitation, for example, the outpatient clinical hypothesis limits the prescribing time to be generally not more than 7 days, special cases need examination but can not exceed 1 month, and the emergency clinical hypothesis limits the prescribing time to be not more than 3 days; and performing overtime effect reminding when the writing is less than 2 times within 24 hours of recording the emergency course.
Illustratively, the quality control of the context content is realized by intelligently checking and prompting the writing content by utilizing a medical knowledge graph according to the context content of a medical record; prompting suspected diagnosis according to written contents such as chief complaints, medical history and the like; prompting possible diagnosis and treatment plans according to the chief complaints and the diagnosis; such as:
patient complaints are: the pain of the right leg caused by the car accident with the limited movement for more than 5 hours;
the current medical history: the patient is suffered from right leg pain and limited movement caused by traffic accident injury 5 hours ago, and the emergency treatment is available in our hospital, and the CT of the emergency treatment shows that: proximal fracture of right tibia;
and (3) diagnosis: fracture of the tibia;
the recommended treatment regimens are: simple screw fixation, bone plate and screw fixation, intramedullary nail fixation, preventive antibacterial treatment, rehabilitation department consultation and the like.
Further, as shown in fig. 4, the post-event management unit 3 includes:
the medical record printing management module 31 is used for limiting printing of medical records with serious defects, and the medical record printing permission is limited to that a doctor can not print, an outpatient department can print without limit, and a self-service machine can print in limited number of copies;
the medical record filing management module 32 is used for automatically filing PDF in a filing server after the zero point of the next day for all the door (emergency) diagnosis electronic medical records which are written and signed;
the post quality control module 33 is used for performing quality control on the medical record according to the quality assessment indexes of the medical record after the electronic medical record is subjected to outpatient (emergency) diagnosis, and obtaining a post quality control result;
and the statistical management module 34 is used for performing medical record retrieval, statistical query of various reports and report butt joint so as to meet the management requirements of doctors on statistical query, quality control and performance of scientific research and management departments and the like.
Illustratively, the medical record printing management module 31 is configured to limit printing of medical records with severe defects, where the medical record printing authority limit is that a doctor cannot print, an outpatient department can print without limit, and a self-service machine can print a limited number of copies; such as: the chief complaints and the current medical history in the initial medical record are required to be not less than 4 characters, and the past history, the epidemiological history, the diagnoses, the diagnosis and treatment plan, the signature and the like are required to be printed; the physician does not have printing authority; the management personnel of the clinic department can print a plurality of copies without limiting the printing; the self-service machine end prints and limits two copies for free, if the medical record is modified, the self-service machine end has twice free printing authorities again, and the patient can pay for self-service printing of the medical record if the number of the free printing authorities exceeds the free limiting number.
Further, the post-quality control module 33 includes:
the automatic quality control sub-module 331 is used for automatically grading according to quality control rules such as completeness, logicality and timeliness of the electronic medical record of the department (emergency) visit, and automatically confirming the quality grade (grade A, grade B or grade C) of the medical record according to the grading to obtain a post quality control result; and the manual quality control sub-module 332 is used for performing manual quality control management on the medical records by quality control personnel, selecting corresponding quality control items according to medical record problems on the basis of automatic quality control, enabling each quality control item to correspond to a corresponding score, manually and automatically grading, and automatically confirming the quality grade of the medical records according to the grading to obtain a post quality control result.
Illustratively, the automatic quality control sub-module 331 is configured to automatically score according to quality control rules such as integrity, logicality, timeliness, and the like of the outpatient (emergency) medical record, and automatically determine quality grades (grade a, grade b, or grade c) of the medical record according to the score to obtain a post-event quality control result; such as: automatically evaluating the medical records of the problems of the existence of main complaints, the existence of medical history and epidemiological history, the existence of physical examination and auxiliary examination, the completeness of diagnosis, the reasonableness of treatment and the like; automatically deducting 10 points if the chief complaint is not filled or the number of words does not meet the requirement; the diagnosis is not filled, 10 grades are automatically deducted, and the quality grade of the medical records is automatically confirmed according to the grade, wherein the grade A medical records are more than 90 grades, the grade B medical records are 75-90 grades, and the grade C medical records are less than 75 grades.
Illustratively, the manual quality control sub-module 332 is configured to perform manual quality control management on medical records by quality control personnel, select corresponding quality control items according to medical record problems on the basis of automatic quality control, each quality control item corresponds to a corresponding score, automatically score by manual operation, and automatically confirm quality grade of the medical records according to the score to obtain a post-event quality control result; such as: whether the chief complaint is filled in according to the symptom and duration format or not, manually selecting and deducting 0-10 points, diagnosing whether the chief complaint is comprehensive or normative, manually selecting and deducting 0-10 points and the like, checking defective items for scoring, automatically obtaining scores, and automatically confirming the quality grade (grade A, grade B or grade C) of the medical record according to the scores.
Further, the manual quality control sub-module 332 includes:
random spot check and quality control, wherein quality control personnel can randomly spot check any number of medical records in a certain period of time (for example, spot check 50 medical records in one month), and the random spot check comprises various modes such as hospital random spot check, department random spot check, physician random spot check and the like;
and (4) specifying quality control, namely performing medical record quality control through conditions such as a specified time period, an institution, a department, a doctor, a title and/or a patient.
Furthermore, the post-affair quality control result can be fed back to a chief manager of a department and/or a medical record writing doctor at a designated time through a Hospital Information System (HIS) message platform or an enterprise WeChat message.
Further, the statistics management module 34 includes:
the medical record retrieval submodule 341 is used for performing combined retrieval on the contents of the (emergency) medical record of an emergency department in any self-defined condition, can perform combined retrieval in any time period and any structured items (such as chief complaints, current medical history, diagnosis and the like) in a self-defined manner, can also perform self-defined retrieval result list, and performs data desensitization on the retrieval results to meet the retrieval requirements of any medical record;
the statistical query submodule 342 is used for counting the writing conditions, quality control conditions, medical record modification and approval conditions and the like of medical records of departments, areas and/or whole hospitals in any time period;
the report docking sub-module 343 is used for making quality control reports and performance reports according to the writing conditions of departments and the individual writing conditions of doctors, and performing data docking with a Hospital Information System (HIS) message platform, an enterprise WeChat, a hospital performance evaluation system and/or a hospital comprehensive office system.
Illustratively, the medical record retrieval submodule 341 is configured to perform combined retrieval on (urgent) medical record contents at an arbitrary user-defined condition joint retrieval gate, perform combined retrieval at an arbitrary time period and an arbitrary structured item (such as chief complaints, current medical history, diagnosis, and the like) by user-defined, and perform data desensitization on retrieval results to meet retrieval requirements of arbitrary medical records; such as: in 1 month of query, the chief complaints comprise fever, the current medical history comprises cough, the diagnosis comprises bronchitis, departments comprise patient information of paediatrics and the like, the retrieval results comprise lists of various contents such as patient names, sexes, ages, treatment departments, treatment times, chief complaints, current medical history, past medical history, epidemiological history, diagnosis, treatment plans, doctors and the like, the lists can be customized, data desensitization is carried out on the inquired basic information of the patients, and sensitive information such as patient names, identity card numbers and the like is not completely displayed.
Illustratively, the statistical query sub-module 342 is configured to count writing situations, quality control situations, examination and approval situations of medical records of departments, areas and/or entire hospitals, and the like in any time period; such as: the case history writing condition comprises the total writing amount (rate), the first-level department writing amount (rate), the second-level department writing amount (rate) and/or the accounting unit writing amount (rate), and the report contents comprise the time, the departments, the accounting units, the courtyards, the writing amount, the writing rate, the qualified amount, the qualified rate and the like; the quality control condition report comprises an automatic quality control report and a manual quality control report; the report contents comprise date, department, doctor, problem, score, grade evaluation and the like. The medical record modification and approval condition report can inquire the content of medical record modification conditions, modification reasons, approvers, approval time and the like of all departments in the whole hospital within a certain time period.
Illustratively, the report interfacing sub-module 343 is configured to make quality control reports and performance reports according to the writing conditions of departments and doctors, and interface data with a Hospital Information System (HIS) message platform, an enterprise WeChat, a hospital performance evaluation system and/or a hospital comprehensive office system; the quality control report can be fed back to a department master or a medical record writing doctor at a designated time (monthly, next day or immediately) through a Hospital Information System (HIS) message platform or an enterprise WeChat message; the performance report contents comprise contents such as departments, doctors, job numbers, identity card numbers, job titles, job/retirement, the number of patients in attendance, written medical record numbers, writing rates, qualified medical record numbers, qualified rates and the like; the hospital performance department gives performance rewards or punishments according to the writing quality of the medical record of the medical staff in the performance report, and brings the writing rate of the department into the comprehensive objective assessment of the department; and quality control management departments (such as an outpatient department) report the writing condition of medical records of each department and doctors in a hospital comprehensive office system every month, and the departments and doctors with the medical record writing rate of less than 80% carry out hospital-wide report.
Further, the right management unit 4, as shown in fig. 5, includes:
the retrieval authority management module 41 is used for authority control of a doctor for retrieving medical record information of a patient, and limits that the doctor can only retrieve and access all medical record information of the patient in the whole life cycle of the hospital, including the medical record of the current (emergency) examination, the medical record of the patient in hospital, the physical examination record, the examination result, the vital sign record and the like;
the quotation authority management module 42 is used for authority control of the doctor for quotation of the medical record information of the patient, and limits that the doctor can only quote partial contents of all medical record information of the patient to be treated in the whole life cycle of the hospital and can not quote any medical record information of other patients; the modification authority management module 43 is used for controlling the modification authority of the electronic medical record for the doctor in the department of emergency treatment, the medical record modification authority is limited after the medical record is printed, and the modification authority needs to be applied and examined and approved;
and the quality control authority management module 44 is used for controlling the post-affair quality control authority of the electronic medical record for outpatient (emergency) examination and setting three-level management authorities of department quality control, outpatient department quality control and medical record department quality control.
Illustratively, the right management module 42 is used for controlling the right of a doctor to refer to medical record information of a patient, and is limited in that the doctor can only refer to partial content of all medical record information of a patient receiving a treatment in the hospital in the whole life cycle, and cannot refer to any medical record information of other patients; if doctors quote the medical records of the department of antecedent and urgent clinic, only the contents of chief complaints, current medical history, past medical history, allergy history and the like can be quoted, but the contents of epidemiological history, diagnoses, diagnosis and treatment plans, medical orders, signatures and the like can not be quoted, and any medical record information of other patients can not be quoted.
Further, the modification right management module 43 manages the outpatient and the emergency patients separately; the outpatient needs to judge whether the patient is on the current date of the clinic, if so, the doctor applies for the modification right and then automatically checks, and the medical record can be modified in real time; if not, the doctor can modify the medical record only after the doctor applies for the modification authority and needs to be audited by an outpatient department; the emergency patient does not need to judge the patient's date of seeing a doctor, and the doctor can automatically check the date after applying for the correction authority, and can correct the medical record in real time.
Illustratively, the modification right management module 43 manages the outpatient and emergency patients separately; the outpatient medical record modification authority management limits that after a patient prints a medical record, whether the patient is on the current date of the patient's visit is judged, if so, only authority application is needed in the system, a patient visit card is read, the condition that a doctor and a patient are on site simultaneously is ensured, the modification reason is filled and submitted, the system automatically checks, and a doctor can modify the medical record in real time; if not, the medical record is modified successfully by the doctor, and the doctor can modify the medical record only after submitting the medical record to the examination of the department of outpatient service; the management of the medical record modification authority of the emergency patient is limited in that after the patient prints the medical record, only the authority application is needed in the system, the patient treatment card is read, the condition that the doctor and the patient are on site simultaneously is ensured, the modification reason is filled and submitted, the system automatically checks, and the doctor can modify the medical record in real time.
Further, the quality control authority management module 44 sets three levels of management authorities of department quality control, clinic quality control and medical record department quality control. The department quality control designates quality control personnel by the department to carry out the quality control of medical records in the department, and the authority is set to view and control the electronic medical records for emergency treatment at the door of the department; the outpatient department quality control is used for carrying out quality control and management on the medical record of the department (emergency) examination of the whole hospital by outpatient department quality control personnel, and the authority is set to be used for checking and quality control on the electronic medical record of the department (emergency) examination of each department door of the whole hospital; the quality control of the medical record department is performed by quality control personnel of the medical record department on the quality control and management of the outpatient (urgent) medical records of the whole hospital, and the authority is set to view and quality control the electronic medical records of outpatient (urgent) medical records filed in each department of the whole hospital.
The above description is only a preferred embodiment of the present invention and is not intended to limit the present invention, and various modifications and changes may be made by those skilled in the art. Any modification, equivalent replacement, or improvement made within the spirit and principle of the present invention should be included in the protection scope of the present invention.
Claims (10)
1. A quality control management method for an electronic medical record of an outpatient (urgent) clinic is characterized by comprising the following steps:
setting quality control and management rules of the electronic medical record for the outpatient (emergency) diagnosis;
performing quality control management on the electronic medical record for clinic (emergency) diagnosis according to the quality control and management rules;
and obtaining the quality control result of the electronic medical record of the department (emergency) examination, making a quality control management report, and performing performance evaluation and quality control feedback.
2. The utility model provides an outpatient (urgent) examination electronic medical record quality control management system which characterized in that includes:
the rule setting unit is used for setting quality control and management rules of the electronic medical record for clinic (emergency) diagnosis;
the process management unit is used for real-time quality control and management in the process of writing medical records by a doctor and simultaneously recording all medical record operations of the doctor;
the post management unit is used for performing printing management, filing management, post quality control management, various statistical queries, performance association and other management on the medical records;
and the authority management unit is used for managing various medical record operation authorities (such as retrieval authority, reference authority, modification authority, quality control authority and the like) of doctors and quality control personnel.
3. The system of claim 2, wherein the process management unit comprises:
the process quality control module is used for automatically controlling the quality of medical records according to medical record quality assessment indexes (such as completeness, logicality, timeliness and context content examination) in the writing process of the electronic medical records of the outpatient (emergency) service;
and the operation trace-remaining module is used for acquiring all operations of a doctor in the process of writing a medical record and displaying trace-remaining.
4. The system of claim 2, wherein the post management unit comprises:
the medical record printing management module is used for limiting printing of medical records with serious defects, and the medical record printing permission is limited to that a doctor can not print the medical records, the outpatient department can print the medical records infinitely, and a self-service machine can print the medical records in limited number of copies;
the case history filing management module is used for automatically realizing PDF filing on a filing server after the zero point of the next day for all the door (emergency) diagnosis electronic case histories which are written and signed;
the post-event quality control module is used for performing quality control on the medical record according to the medical record quality assessment indexes after the electronic medical record of the outpatient (urgent) diagnosis is finished, and obtaining a post-event quality control result;
the system is used for medical record retrieval, statistical query of various reports and report butt joint so as to meet the management requirements of doctors on statistical query, scientific research and management departments on quality control and performance and the like.
5. The system of claim 4, wherein the post-event quality control module comprises:
the automatic quality control sub-module is used for automatically grading according to quality control rules such as the integrity, the logicality and the timeliness of the electronic medical record of the department (emergency) visit, and automatically confirming the quality grade (grade A, grade B or grade C) of the medical record according to the grading to obtain a post-affair quality control result;
and the manual quality control sub-module is used for performing manual quality control management on the medical records by quality control personnel, selecting corresponding quality control items according to medical record problems on the basis of automatic quality control, manually grading each quality control item corresponding to a corresponding score, and automatically confirming the quality grade of the medical records according to the grading to obtain a post quality control result.
6. The system of claim 4, wherein the statistical management module comprises:
the medical record retrieval submodule is used for arbitrarily customizing the content of the condition combined retrieval gate (emergency) diagnosis electronic medical record, can customize an arbitrary time period and arbitrary structured project combination combined retrieval, and can also customize a retrieval result list, and the retrieval result is subjected to data desensitization to meet the retrieval requirement of any medical record;
the statistical query submodule is used for counting the writing condition, the quality control condition, the modification and approval condition and the like of medical records of departments, areas and/or whole hospitals in any time period;
and the report docking sub-module is used for making a quality control report and a performance report according to the writing condition of the department and the personal writing condition of the doctor, and performing data docking with a Hospital Information System (HIS) message platform, an enterprise WeChat, a hospital performance evaluation system and/or a hospital comprehensive office system.
7. The system for quality control and management of the outpatient (emergency) medical record as claimed in claim 4, wherein the report docking sub-module comprises: the quality control report can be fed back to a department master or a medical record writing doctor at a designated time (monthly, next day or immediately) through a Hospital Information System (HIS) message platform or an enterprise WeChat message; and the hospital performance department gives performance rewards or punishments according to the writing quality of the medical records of the physicians in the performance report, brings the writing rate of the department into the comprehensive objective assessment of the department, and reports the writing conditions of the medical records of each department and the physicians in the comprehensive office system of the hospital every month.
8. The system of claim 2, wherein the rights management unit comprises:
the retrieval authority management module is used for the authority management and control of the doctor for retrieving the medical record information of the patient, and limits that the doctor can only retrieve and review all the medical record information of the patient in the whole life cycle of the hospital, including the medical record of the current (emergency) examination, the medical record of the patient in hospital, the physical examination record, the examination and examination result, the vital sign record and the like;
the quotation authority management module is used for the authority control of the doctor for quotation of the medical record information of the patient, and limits that the doctor can only quote partial contents of all medical record information of the patient to be treated in the whole life cycle of the hospital and can not quote any medical record information of other patients;
the modification authority management module is used for controlling the modification authority of the electronic medical record for the doctor in the department of emergency treatment, the medical record modification authority is limited after the medical record is printed, and the modification authority needs to be applied and examined and approved;
and the quality control authority management module is used for controlling the post-affair quality control authority of the electronic medical record for the outpatient (emergency) examination and setting three-level management authorities of department quality control, outpatient department quality control and medical record department quality control.
9. The system for quality control of electronic medical records for outpatient (emergency) treatment according to claim 8, wherein the modification right management module manages outpatient and emergency patients separately; the outpatient needs to judge whether the patient is on the current date of the clinic, if so, the doctor applies for the modification right and then automatically checks, and the medical record can be modified in real time; if not, the doctor can modify the medical record only after the doctor applies for the modification authority and needs to be audited by an outpatient department; the emergency patient does not need to judge the patient's date of seeing a doctor, and the doctor can revise the case history in real time after applying for the revision authority and automatically audits.
10. The system for quality control management of the outpatient (emergency) medical record as claimed in claims 6 and 7, wherein the attribution of the quality control report and/or the performance report of the outpatient (emergency) medical record at least comprises: a hospital performance evaluation system, a Hospital Information System (HIS) messaging platform, enterprise wechat, and/or a hospital integrated office system.
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Cited By (2)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN115691742A (en) * | 2023-01-03 | 2023-02-03 | 江西曼荼罗软件有限公司 | Electronic medical record quality control method, system, storage medium and equipment |
| CN116759039A (en) * | 2023-08-11 | 2023-09-15 | 北方健康医疗大数据科技有限公司 | Medical record quality control method, system and storage medium |
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Cited By (2)
| Publication number | Priority date | Publication date | Assignee | Title |
|---|---|---|---|---|
| CN115691742A (en) * | 2023-01-03 | 2023-02-03 | 江西曼荼罗软件有限公司 | Electronic medical record quality control method, system, storage medium and equipment |
| CN116759039A (en) * | 2023-08-11 | 2023-09-15 | 北方健康医疗大数据科技有限公司 | Medical record quality control method, system and storage medium |
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