In 2023, the improvement targets (information-related) of quality control work of various disciplines are as follows:
(1) To improve the correct rate of main diagnostic codes on the first page of medical records, the core strategy is to clarify the responsibilities and tasks of management, clinic, medical records and other departments in the whole process of medical record first page and medical record quality management, so as to make it an important starting point for improving medical quality. Use quality management tools to find and analyze the factors that affect the organization to achieve this goal, and put forward continuous improvement measures and implement them.
(2) To improve the utilization rate of outpatient electronic medical records, the core strategy is that medical institutions set up special working groups composed of medical departments, clinical departments, medical technology departments and information departments, and improve the working systems and mechanisms related to the writing and management of outpatient electronic medical records. Strengthen the connotation quality control of electronic medical record writing and improve the standardization of writing. Conditional medical institutions provide new medical record input methods such as voice input and image extraction to improve the convenience of electronic medical records. Establish a monitoring and evaluation mechanism for the utilization rate of outpatient electronic medical records in this institution, analyze the factors affecting the realization of this goal, and continuously improve the utilization rate of outpatient electronic medical records.