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产科病案无纸化管理的实施

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通过介绍某妇产医院梳理产科病案无纸化管理的制约因素并针对性地开发系统,实现产科病案无纸化的过程,探讨无纸化管理带来的优点及其衍生的管理制度调整、风险控制问题.为解决产科病案纸质归档率低、归档质量参差不齐等问题,实现同质化管理,梳理制约产科病案无纸化管理的关键问题,并分别通过在线审核胎心监护报告、医患双方知情同意书电子签名生成PDF文件、门诊报告及各相关业务系统文档导入无纸化管理系统,从而实现产科病案无纸化归档,达到提质增效、规范诊疗流程的效果.无纸化管理后需加强风险控制,持续优化管理模式.精准的需求分析、系统持续测试优化及全员使用培训,可以提高系统的适用性,增强临床接受度,对正在进行病案归档模式转型的医院有参考意义.
Implementation of Paperless Medical Records of Obstetric Department
By introducing a maternity hospital to sort out the constraints of paperless management of obstetric medical records and develop a targeted system to achieve the process of paperless management of obstetric medical records,this article discusses the advantages of paperless management and the resulting management system adjustments and risk control issues.In order to solve the problems of low paper filing rate and uneven filing quality in obstetric medical records,achieve homogenization management,sort out the key issues that restrict the paperless management of obstetric medical records,and solve them through online review of fetal heart monitoring reports,electronic signature of informed consent forms between doctors and patients to generate PDF files,import outpatient reports and related business system documents into the paperless management system,so as to achieve paperless archiving of obstetric medical records,improve quality and efficiency,and standardize the diagnosis and treatment process.After paperless management,it is necessary to strengthen risk control and continuously optimize the management model.Precise demand analysis,continuous system testing and optimization,and training for all staff can improve the applicability of the system,enhance clinical acceptance,and have reference significance for hospitals undergoing transformation of medical record filing mode.

Obstetrics departmentPaperlessElectronic medical recordsMedical informatization

朱艳艳、林明璐、孙如鹏、毛辉、黄文钦

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厦门弘爱妇产医院医务部,福建省,厦门市,361013

厦门弘爱妇产医院信息化部,福建省,厦门市,361013

产科 无纸化 电子病历 医疗信息化

2024

中国病案
中国医院协会

中国病案

CSTPCD
影响因子:1.197
ISSN:1672-2566
年,卷(期):2024.25(10)