Currently the processing of China's case management is mainly the first page of the case.
The case is the medical staff in the process of medical activities formed on the patient's disease occurrence, development, diagnosis and treatment of objective records, is the clinical medical, scientific research and teaching, insurance claims important original information.
It is also an objective basis for evaluating the patient's health status, and an important legal basis for handling, arbitrating and adjudicating medical disputes. Real reflection of the patient's condition for this case the quality of the advantages and disadvantages, not only reflects the hospital's management level and quality of care, but also reflects the basic quality of medical personnel and professional competence.
The quality control of case content is mainly to monitor the timeliness, completeness, accuracy and scientificity of case records. The first level of case quality control (residents of each clinical department), mainly responsible for the writing of personal medical records and self-examination and rectification, etc.; the second level of case quality control (departmental medical quality control team), responsible for the quality control of medical records before discharge.
That is, the medical record link quality control, three-level case quality control (case section quality control physicians and organizers), mainly responsible for the quality of writing and completeness of the case checking work. The fourth level of case quality control (medical office or case management committee) is responsible for random checking the quality of the case.
The role of hospital management in case information management is as follows:
1. Improve the professional knowledge of case management personnel, and increase the relevant equipment for case management, such as computers and related management methods of literature and books. Guarantee the case management personnel's professional skills, have a certain degree of patience and enthusiasm for the work.
2, the hospital's history of the case for the collection of entry, according to the case of the attributes of the classification and organization, so that the case management to achieve the effect of rapid query and borrowing, the case statistics, analyze the existing problems and develop appropriate measures to solve them.
3. The application of electronic medical records reduces the error rate of doctors' manual writing and improves the efficiency of work while providing the quality of medical records.
4, the access system for the case of a reasonable arrangement, the access to the reference staff in the access to the reference according to the conditions of input, timely to find the need for case information, to ensure that the circulation of the case is convenient.