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[1]刘媛汪刚.基于PDCA的病案数据质量风险治理研究[J].中国卫生质量管理,2025,32(02):38-41.[doi:10.13912/j.cnki.chqm.2025.32.2.10]
　LIU Yuan,WANG Gang.Research on Risk Governance of Medical Record Data Quality Based on PDCA[J].Chinese Health Quality Management,2025,32(02):38-41.[doi:10.13912/j.cnki.chqm.2025.32.2.10]

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基于PDCA的病案数据质量风险治理研究

《中国卫生质量管理》[ISSN:1006-7515/CN:CN 61-1283/R] 卷: 32 期数: 2025年02期页码: 38-41 栏目: 医疗质量出版日期: 2025-02-15

Title:: Research on Risk Governance of Medical Record Data Quality Based on PDCA

作者:: 刘媛汪刚; 上海市胸科医院/上海交通大学医学院附属胸科医院

Author(s):: LIU Yuan; WANG Gang; Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine

关键词:: 数字化转型; 病案; PDCA; 数据质量

Keywords:: Digital Transformation; Medical Record; PDCA; Data Quality

分类号:: R197.323

DOI:: 10.13912/j.cnki.chqm.2025.32.2.10

文献标志码:: B

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。

Abstract:: ObjectiveTo 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.MethodsPDCA 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.ResultsThe 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.

参考文献/References:

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更新日期/Last Update: 2025-02-15