A medical record multidimensional intelligent closed-loop quality control system and a quality control method

Abstract

This invention discloses a multi-dimensional intelligent closed-loop quality control system and method for medical records, relating to the fields of medical quality management and medical record content improvement. The system includes a data acquisition module, a multi-dimensional quality control rule base module, an automatic quality control module, a manual quality control module, a closed-loop management module, a perioperative-specific quality control module, a data statistics module, and an access control module. By collecting medical record and surgical data in real time, it automatically identifies defects according to four rules: timeliness, completeness, accuracy, and standardization. This enables precise defect location, closed-loop rectification and appeal processes, hierarchical quality control at the hospital and department levels, and perioperative-specific verification, generating hospital and department-level statistical reports. This invention can manage the quality of operating medical records in real time, automatically, and in a closed loop, improving medical safety and management efficiency, and enhancing the quality of medical record content. It is applicable to medical record quality management at all levels of medical institutions.

Description

Technical Field

[0001] The present invention relates to the technical field of medical quality management and connotation improvement of medical records, in particular to a multi-dimensional intelligent closed-loop quality control system and quality control method for in-progress medical records. Background Art

[0002] Medical records are the core carrier of medical activities, and the quality of medical record writing is directly related to medical safety, prevention of medical disputes and hospital management level. Among them, quality control of in-progress medical records is a key link to ensure medical quality and prevent medical risks. At present, the quality control of in-progress medical records in medical institutions mostly relies on manual spot check and manual verification, which has such problems as inability to perform real-time quality control, inconsistent standards, inaccurate defect location, unclosed rectification feedback and incomplete data statistics. Meanwhile, as a high-risk link, perioperative medical record quality control relies on manual verification of surgical information and medical record records, which is prone to omission, timeout, non-standard writing and other situations.

[0003] Current quality control of in-progress medical records in hospitals generally has the following technical problems: quality control relies on manual verification, which has low efficiency and high missed detection rate, and cannot realize real-time quality control; quality control rules are scattered, standards are not uniform, and timeliness, completeness, accuracy and standardization are difficult to be quantitatively controlled; defect location is inaccurate, it is inconvenient for physicians to modify, and there is a lack of closed-loop mechanism for trace retention and appeal; the dimension of data statistics is single, which cannot realize reference analysis at hospital and department levels; perioperative quality control relies on manual verification and is disconnected from the anesthesia management system for surgery, so key nodes are prone to out of control. Therefore, there is an urgent need for a set of automated, intelligent, closed-loop in-progress medical record quality control system and method. Summary of the Invention

[0004] The purpose of the present invention is to overcome the deficiencies of the prior art, provide a multi-dimensional intelligent closed-loop quality control system and quality control method for in-progress medical records, realize automatic quality control, hierarchical manual quality control, closed-loop rectification, perioperative special control and multi-dimensional statistical analysis, and improve the efficiency of medical record quality control and the connotation quality of medical records.

[0005] 1. System Composition A multi-dimensional intelligent closed-loop quality control system and quality control method for in-progress medical records, comprising: a medical record data acquisition module, a multi-dimensional quality control rule base module, an automatic quality control module, a manual quality control module, a closed-loop management module, a perioperative special quality control module, a data statistics and report module, and a permission management module.

[0006] (1) Medical record data acquisition module: interfaces with electronic medical record systems, surgical anesthesia systems, and medical order systems to acquire medical record text, time nodes, physician information, and surgical information; (2) Multi-dimensional quality control rule base module: configured to store and execute four categories of quality control rules including timeliness, completeness, accuracy and standardization, which can be set according to specific diseases or characteristic disciplines and supports custom configuration; (3) Automatic quality control module: performs real-time quality control on running medical records, automatically identifies defects, locates the defect locations, and generates a defect list; (4) Manual quality control module: Supports two-level manual quality control at the hospital and department levels (department self-inspection and functional department supervision), can reference automatic quality control results, and supports defect annotation and commentary; (5) Closed-loop management module: provides functions for defect location and modification, appeal, review, feedback, record retention, and accuracy statistics; (6) Perioperative quality control module: Linked with the hand anesthesia system, it enables automatic verification of surgeon rounds, preoperative summaries, surgical records, and multidisciplinary discussions of level four surgeries; (7) Data statistics and reporting module: Generate reports such as department details, hospital-wide summary, pass rate, defect distribution, and perioperative examination form; (8) Permission Management Module: Divides the permissions into five levels: attending physician, department quality control officer, department director, functional department, and hospital-level manager.

[0007] 2. Quality Control Rules (1) Timeliness rules: Admission records must be completed within 24 hours; the first course of treatment must be completed within 8 hours; postoperative records must be completed within 24 hours; resuscitation records must be completed within 6 hours; blood transfusion process records must be completed within 6 hours after blood transfusion, and post-blood transfusion evaluation must be completed within 48 hours; critical values ​​must be completed within 6 hours; discharge records or death records must be completed within 24 hours; periodic summaries must be recorded every 30 days; transfer records must be completed within 24 hours; senior physician review and approval must be completed within 24 hours; failure to complete the first course of treatment, admission records, and discharge records on time will result in timeouts.

[0008] (2) Completeness rule: The completeness of admission records, initial medical history, surgical records, preoperative summary, preoperative discussion, emergency record, difficult case discussion, blood transfusion record, critical value record, death record, death case discussion, transfer record, stage summary, discharge record, etc. will be verified; blank, XX, missing items will be judged as incomplete.

[0009] (3) Accuracy rules: including the control of time limits for three-level ward rounds, consultations, death discussions, time logic of medical record records, and transfer records; the specific content is: attending physicians conduct ward rounds within 48 hours and chief physicians conduct ward rounds within 72 hours; consultation records must be completed within 24 hours; death discussions must not be earlier than death records and must be completed within 7 days; the time of medical record records must meet the frequency requirements according to the nursing level; diagnosis and surgery-related information for male and female patients are automatically determined.

[0010] (4) Normative rules: including the qualifications of the writing personnel, the three-level ward round structure, the writing and review of surgical records, the standardization of consultation content, and the requirement that whoever conducts the ward round reviews and reviews the records; the specific content is as follows: only physicians registered in this hospital are qualified to write the first course of medical records; the frequency requirements for ward rounds by three-level physicians; the principle of whoever conducts the ward round reviews and reviews the records; the surgical physician writes the medical record on the day of surgery; the surgeon / assistant writes the surgical record and the surgeon reviews and reviews it; the reason for the consultation application is clear, the consultation opinion is ≥10 words and the patient must be seen; the three-level physicians record the records in a standardized manner on the first page of the medical record.

[0011] 3. Quality control methods (1) Data acquisition: Real-time acquisition of data related to electronic medical records, hand anesthesia system, and medical orders; (2) Automatic quality control: Real-time quality control according to four major rules, with defects in each medical record displayed and automatically located; (3) Physician rectification: One-click jump to modification, appeal is allowed with reasons; (4) Record keeping: Save records of modifications, appeals, feedback, and review, and calculate the adoption rate and accuracy rate; (5) Tiered manual quality control: Departments conduct self-inspections, and the medical affairs department conducts inspections. Medical records with multiple defects can be marked as unqualified medical records. (6) Perioperative quality control: Linked with the surgical anesthesia system, automatically checking the contents of surgeon rounds, preoperative documents, surgical records, and preoperative multidisciplinary discussions for level 4 surgeries; (7) Data statistics: Generate daily, monthly, quarterly and annual reports according to permissions, realize data summary and data traceability, and drill down to departments, doctors and patients. 4. Description of the attached drawings

[0012] Figure 1 is a structural framework diagram of the system of the present invention. Explanation of reference numerals in the attached figures: 1. Medical record data acquisition module; 2. Multi-dimensional quality control rule base module; 3. Automatic quality control module; 4. Manual quality control module; 5. Closed-loop management module; 6. Perioperative special quality control module; 7. Data statistics and reporting module; 8. Access control module. 5. Detailed Implementation

[0013] Example 1: Automated Quality Control and Rectification After a patient is admitted to the hospital, the system monitors the time limit for writing medical records in real time, automatically prompts and locates items that are overdue; after the physician completes the modification, the system verifies again; for items that are misjudged by the system, the physician can file an appeal, which is reviewed and confirmed by the medical affairs department, and the system retains the modification and review records throughout the process.

[0014] Example 2: Perioperative quality control The system obtains surgical information from the anesthesia system: automatically checks the surgeon's ward round records 24 hours before surgery, the completion status of the preoperative summary and preoperative discussion, and the completion status of the surgical record within 24 hours; for level 4 surgeries, a pop-up prompt is made and the preoperative multidisciplinary discussion is checked to verify whether the participants meet the multidisciplinary requirements.

[0015] Example 3: Statistical Report The system automatically generates detailed lists of defects in departmental medical records, lists of records about to expire / already expired; summary tables of timeliness, completeness, accuracy, and pass rate; a summary of all hospital-wide medical records; a summary of departmental issues; and a perioperative quality control checklist. It supports viewing, exporting, and printing by role and level.

Claims

1. A multi-dimensional intelligent closed-loop quality control system and method for operating medical records, characterized in that, include: The system includes a medical record data acquisition module, a multi-dimensional quality control rule base module, an automatic quality control module, a manual quality control module, a closed-loop management module, a perioperative specialized quality control module, a data statistics and reporting module, and an access control module. The multi-dimensional quality control rule base module includes four categories of quality control rules: timeliness, completeness, accuracy, and standardization. The perioperative specialized quality control module interfaces with the surgical anesthesia system to enable automatic verification of surgeon rounds, preoperative summaries, surgical records, and preoperative multidisciplinary discussions for level four surgeries.

2. The system according to claim 1, characterized in that, The defect closed-loop management module has automatic defect location, modification, appeal, submission, review, record retention, and quality control adoption rate and accuracy statistics.

3. The system according to claim 1, characterized in that, The manual quality control module supports two levels of mode: departmental self-inspection and medical affairs department supervision. It can reference the results of automatic quality control and perform manual supplementary inspections, defect annotations, and comments.

4. The system according to claim 1, characterized in that, The data statistics and reporting module can generate daily departmental details, timeliness / completeness / accuracy / pass rate summary tables, running medical record pass rate tables, departmental problem summary tables, and perioperative quality inspection tables.

5. A method for intelligent quality control of medical records based on multi-dimensional rules, characterized in that, include: (1) Collect data from electronic medical records, hand anesthesia systems, and medical orders; (2) Based on the rules of timeliness, completeness, accuracy and standardization, automatic quality control and defect location can be carried out by disease type or discipline; (3) When a physician modifies or appeals a defect, the system retains a complete record of the process; (4) Departmental self-inspection and medical affairs department supervision are graded and manually controlled, prompting departments to provide feedback and make corrections, and automatically marking unqualified medical records; (5) Automatic verification in conjunction with the perioperative anesthesia system; (6) Generate multi-dimensional statistical reports according to permissions to achieve closed-loop management.

6. The method according to claim 5, characterized in that, Timeliness rules include 24-hour time limit for admission records, 8-hour time limit for initial medical history, 24-hour time limit for surgical records, 6-hour time limit for resuscitation records, and time limit control for blood transfusions and critical values. Key documents will be locked if the time limit is exceeded.

7. The method according to claim 5, characterized in that, The integrity rule considers blank, XX, unfilled, and placeholder content as incomplete.

8. The method according to claim 5, characterized in that, Perioperative quality control includes: verification of surgeons' preoperative and postoperative ward rounds, verification of preoperative summaries and discussions, verification of surgical record time limits, and verification of multidisciplinary discussions for level 4 surgeries.

9. The method according to claim 5, characterized in that, The system supports five levels of access control: including attending physician, department quality control officer, department director, medical affairs office, and hospital-level administrators, with data drill-down to departments, physicians, and patients.

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