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目的为了探讨新的病案监测模式的作用及意义。方法采用回顾性对照进行比较研究,过去实行病案终末监测,现实行人机结合、逐级监控、全员参与、主动互监的病案监测的新模式。结果原监测模式甲级病案率多年来一直徘徊在91.0%左右;新的监测模式全病案质量逐月提高,到目前为止在院病案甲级病案率达98.2%,出院病案甲级病案率100%,而且确保了病案内容的真实性、有效性及监测的公正性。结论随着数字化医院的建设,将有越来越多的医院具备信息化管理平台,可以实现新的病案监测模式,我相信该模式的推广应用必将对病案监测改革方面产生重大影响。
Objective To explore the role and significance of the new medical record monitoring model. Methods A comparative study was conducted using retrospective comparisons. In the past, a new model of medical record monitoring was implemented, which was a combination of patient-machine monitoring, step-by-step monitoring, full participation, and active monitoring. Results The rate of Grade A disease in the original monitoring model has been around 91.0% for many years; the quality of the new monitoring model has increased month by month. The rate of Grade A disease in the hospital case reached 98.2%, and the rate of Grade A disease in the discharged case was 100%. , but also to ensure the accuracy of the contents of the medical record, effectiveness and fairness of monitoring. Conclusion With the construction of digital hospitals, more and more hospitals will have informatization management platforms that can implement new medical record monitoring models. I believe that the promotion and application of this model will have a major impact on the medical record monitoring reform.