Reflection on the construction of electronic medical record quality control system under the back-ground of high-quality development
10.3969/j.issn.1671-332X.2025.01.018
- VernacularTitle:高质量发展背景下医院电子病历质控体系建设的思考
- Author:
Zhencai DONG
1
Author Information
1. 天津市儿童医院/天津大学儿童医院/天津市儿童出生缺陷防治重点实验室 天津 300134
- Publication Type:Journal Article
- Keywords:
Electronic medical records;
Data quality;
Indicator;
System
- From:
Modern Hospital
2025;25(1):65-67,71
- CountryChina
- Language:Chinese
-
Abstract:
Objective To establish an evaluation system for electronic medical record quality control,effectively en-hance data quality control capabilities,accelerate the construction of the theoretical framework for electronic medical records,and promote the high-quality development of public hospitals with the construction of the electronic medical record quality control sys-tem as the core.Methods Based on the Hall three-dimensional structure model,a quality management system structure is con-structed,integrating the dimensions of time,logic,and knowledge,effectively leveraging regulatory mechanisms,and improving management levels to form an efficient management system applicable to clinical practice and continuous functional improvement.Results The defect rates of various categories of medical records have continuously decreased,and the defect rates of consulta-tion records and surgical records have shown significant reductions.Conclusion The construction of the inpatient electronic medical record quality management system based on the Hall three-dimensional structure can effectively promote the efficient oper-ation of the electronic medical record system and play a guiding role in functionality.
