A quality control system and method for writing hospital medical records

Abstract

The invention provides a doctor records writing quality control system and production method thereof. The system comprises a medical record input device, a host computer 1, a host computer 2, a host computer 3 and a mobile phone; the host computer 1, the host computer 2 and the host computer 3 are connected sequentially through specialized internal network lines. The host computer 2 is connected with the doctor record input device through wireless network communication. The host computer 2 is connected with the mobile phone through the China Mobile Network; the doctor record input device is in a book shape,and comprises a processor, a memory, a wireless network card, a touch screen and a finger print reader. The processor is connected with the memory, the wireless network card, the touch screen and the finger print reader respectively. the system has the advantages that the system can effectively constrain the doctors to write medical records with quality and quantity guaranteed according to the specification; the management department can quickly and conveniently config and modify the quality control rules and comply with the requirements of policy changes; based on the quality control problems existing in the clinical operation the system can analyze the causes of the problems, it is convenient to impose strict regulation to doctors. It is beneficial to strengthening the management of doctors.

Description

technical field [0001] The invention relates to the technical field of medical information, in particular to a quality control system and method for writing hospital medical records. Background technique [0002] In the process of writing medical records in hospitals, medical personnel obtain relevant information through medical activities such as consultation, physical examination, auxiliary examination, diagnosis, treatment, and nursing, and adopt a problem-oriented approach to analyze different problems of patients one by one, and then summarize and sort them out. Records of medical activities, each diagnosis and treatment process, whether outpatient, emergency or inpatient, must record in detail the reason for the visit, main symptoms, recent changes, and diagnosis and treatment results. In the medical records, each record should indicate the time and be signed by the attending doctor; to prevent medical disputes, the medical record is an important document to record the...

AI Technical Summary

Problems solved by technology

However, there are still many problems in the writing of medical records, which may become a hidden danger of medical disputes; medical records have become one of the most important bases in medical litigation, which means that every word and symbol in the medical records represents a law. Responsibility, every sentence may be used as a legal basis. At the same time, medical records are a double-edged sword. Timely detection of changes in the condition will delay the timing of treatment or rescue, and cause personal injury to the patient. The same objective medical records are also the basis for protecting the legitimate rights and interests of patients; The more standardized, the new quality control rules are conducive to standardizing doctors' medical document writing behavior, making it easier for management departments to set new rules in accordance with new requirements, and to do a good job in clinical quality supervision

At present, the existing hospital medical record writing system has the following defects: 1) During the operation of the medical record writing system, clinicians sometimes cannot write medical records on time with quality and quantity, and the quality control after the event cannot supervise or eliminate such clinical Non-standard operation can not better help the management department to achieve the purpose of quality supervision; 2) The medical record writing system relies on the quality control rules of mandatory program control, which has poor scalability. The new quality control rules need to modify the program code and release a new version, so that the management department cannot configure the new quality control rules conveniently and quickly; the flexibility is poor. When the original rules change, the system must also modify the corresponding programs, making the rules Changes are time-consuming and labor-intensive;

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