临床路径实施过程中的病案质量控制

临床路径是一种规范医护人员诊疗行为、控制医疗费用、提高医疗质量的有效临床治疗模式。要确保临床路径的高效实施,必须有完善的病案质量监控手段作为基础。本文探讨了临床路径与病案书写的关系及对病案书写的具体要求,临床路径工作中病案质控的规律及关键要素。在此基础上,提出了制定各单病种临床路径病案质控标准,通过信息技术对临床路径表单中各节点进行病案书写限定等病案质控,并进一步提出了充分利用临床路径病案信息对临床路径方案设计进行修正完善。

Quality Control for Medical Record in the Application of Clinical Pathway

The clinical pathway（CP） is an effective method to regulate the diagnosis and treatment practice of medical professionals,to control medical costs and to improve medical quality and medical record management is the fundamental method to ensure effective practice of the clinic pathway.This paper explores the relations between the clinic pathway and the medical record and the requirements on medical record and the regular pattern and key elements of medical record quality control in the application of clinical pathway.Moreover,the standard for the quality control of medical record writing of each single diagnosis related group in the clinical pathway was formulated,constraints on the writing of medical records in each points of the forms and tables used in the application of clinical pathway were put up through information technology and the idea for using information of digital medical record for the improvement of clinical pathway is proposed.