Practice of structured electronic medical record design and quality management
10.3760/cma.j.cn111325-20221110-00958
- VernacularTitle:结构化电子病历设计及质量管理实践
- Author:
Tian MEI
1
;
Guangnan SHE
;
Yunlong ZHAO
;
You ZHOU
;
Yu ZHAO
;
Yongju YI
Author Information
1. 中山大学附属第六医院信息数据处，广州 510655
- Keywords:
Electronic medical record;
Structured design;
Interconnection;
Quality management;
Data governance
- From:
Chinese Journal of Hospital Administration
2023;39(5):347-351
- CountryChina
- Language:Chinese
-
Abstract:
In order to assist in the standardization and maturity evaluation of national hospital information interconnection, and further standardize the application and management of hospital medical record data, a hospital carried out the practice of design of structured medical records and the corresponding quality management from April 2021. Based on the six sigma quality management method, the hospital had developed universal templates for electronic medical records and a list of candidate electronic medical record templates. The problems faced by medical record data had been analyzed, and improvement strategies had been proposed from three levels: template design, software functionality and management services. The clinical departments were guided to design and develop various structured electronic medical record templates for specialties and specialized diseases, and established a medical record template design and quality management method. The hospital had ultimately designed a total of 614 structured electronic medical record templates that met the actual needs of the hospital. This practice enhanced the scalability of structured templates and quality of the data, and achieved localization and specialization of medical record templates while meeting the requirements of information interconnection and sharing, providing reference for promoting the interconnection and sharing of electronic medical records of hospitals in China.
