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《Chinese Medical Record》 2012-01
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Structural Medical Records and Quality Control of Medical Records

Jiang Ping,Wang Xiaohui,Yu Lei,Department of Information,Changhai Hospital of the Second Military Medical University,Shanghai 200433,China  
Objectives Through computer technology to achieve whole course of medical records quality,especially the real-time monitoring of running medical records,it can improve writing quality of medical records.Methods Relying on structural electronic medical records,it achieves medical records quality control automation,using time,medical orders and template as control node.Results Through quality control by computer,it can enlarge the range of medical records quality control for achieving real-time,standardization medical records quality control.Conclusions Computer technology can improve the quality and efficiency of quality monitoring of medical records that is a direction of future quality control of medical records.
【CateGory Index】: R197.324
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