The quality control of medical records covers the whole business link, and each link needs to do relevant work conscientiously, cooperate with each other, supervise each other, ensure quality and avoid disputes. Quality control projects are mainly carried out in terms of working time and content, and are completed on time and with high quality.
In the hospital quality evaluation system, three links of medical quality are defined: basic quality, link quality and final quality. Basic quality runs through the whole process of quality management and must be constantly grasped; Link quality directly affects the overall medical quality, which must be highly valued; Terminal quality is the comprehensive result of basic quality and link quality, which plays the role of quality feedback control.
The practical application in the electronic medical record business system also covers these three links, namely: self-evaluation of doctors in clinical business departments, quality control of medical records of doctors in departments, quality control of hospital-level medical records in medical departments or quality control departments, and quality control of final medical records in medical records departments.
Self-evaluation of doctors in clinical departments is the first line of defense for the quality control of medical records. Doctors conduct self-evaluation according to the quality control standards formulated by the quality control department or the medical department, and immediately find the problems existing in the quality of medical records and correct them.
The quality control of doctors' medical records is an important link in the quality control of the whole department. The superior (medical department or quality control department) can ensure that the medical record quality of undergraduate course room has been reported statistically, and the subordinate (physician) can control it to prevent potential problems.
The quality control of hospital-level medical records by medical department or quality control department is the last hurdle of quality control. Quality control doctors can spot-check the medical records of all departments in the hospital, one is to check the quality of medical records, and the other is to evaluate the work of quality control staff in various business departments.
The medical record department controls the quality of the final medical record, and this quality control is the most important, because the data after quality control in the medical record department needs to be reported to other medical institutions, such as the data on the first page of medical record needs to be uploaded to the medical management department, health system, drgs and so on. One more thing, efficient and high quality quality control can also avoid medical disputes.