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中文摘要：
目的 探讨门诊病历质量评价和控制系统化、精细化的管理模式和方法,使门诊诊疗质量和服务水平提高。方法 某院基于HIS系统的门诊医生工作站,制定了《门诊病历质量控制评价表》,开展个人、科室、医院多层级质控,结果及时总结反馈,纳入绩效考核,明确奖罚。结果 打破门诊病历患者保存实情下监管困难的僵局,能对门诊病历实时监控、回顾性调阅,病历质量显著提升,PDCA管理初见成效,顺利通过等级医院复审。结论 基于HIS系统的门诊病历质量评价和控制有助于医教研,需进一步制定各专业质控标准,加大内涵质控。未来可通过门诊就医卡实现多医院、中心门诊病历质量对比。
英文摘要：
Objective To discuss the quality evaluation and control of the manage models and methods of the outpa- tient medical records, in order to improve the quality of outpatient diagnose and the level of service. Methods Based on the Hospital Information System （HIS） of outpatient doctors workstation of one hospital, they formulated an ＂outpatient medical record quality control evaluation form＂ to develop the quality control of individual, department, multi - level of hospital, giv- ing feedback timely, clearing rewards and punishment （including the performance appraisal）. Results The problem that pa- tients kept the outpatient records but the hospital could not manage was solved. Medical records were monitored and checked in real time and reviewed retrospectively. Through PDCA management, the hospital successfully passed the grading re - ac- creditation. Conclusion Based on HIS system, outpatient medical records quality evaluation and control is helpful to the medical research and teaching. Further professional quality control standards should be drafted to improve the connotation of quality control. In visiting different hospitals and using the outpatient card, the outpatient service quality of can be compared in the future.
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