Development of outpatient diagnosis assessment system
门诊诊断书考核系统的研发

摘要

目的 为了提高门诊医疗质量，患者服务质量，内蒙古自治区国际蒙医医院门诊诊断书考核工作的有效进行，解决手工考核工作的繁琐，研发门诊诊断书的管理系统。方法 随机抽查我院2021年至2023年的月初日期，选择诊断书的考核专家，成立诊断书专业委员会，每月5日的纸质和电子版的诊断书。包括姓名，年龄，性别，地址，诊断和处理意见，医师签名，日期等内容是否完善，符合情况和漏项情况。结果 一共考核960份门诊诊断书，其中78个地址书写不清，占8%，6个年龄与电子版不符，16个是未大写数字，15个存根与电子不符，4份诊断带问号。2份诊断与电子不符，357份有电子病历，占37.2%，142份医嘱处理，占33.4%，321份处方处理，占33.3%，278检查检验处理，占30%。294纸质版诊断书。结论 门诊诊断书管理系统的研发，可及时筛查出不符合标准的电子与纸质诊断书。

Abstract

Objective: In order to improve the quality of outpatient medical care and patient service, and to effectively carry out the assessment of outpatient diagnosis certificates at Inner Mongolia International Mongolian Medical Hospital, and to solve the tedious manual assessment work, a management system for outpatient diagnosis certificates has been developed. Method: Randomly select the assessment experts for diagnosis certificates in our hospital from the beginning of each month from 2021 to 2023, establish a professional committee for diagnosis certificates, and provide both paper and electronic versions of diagnosis certificates on the 5th of each month. Whether the content including name, age, gender, address, diagnosis and treatment opinion, physician signature, date, etc. is complete, in compliance with the situation and missing items. Result: A total of 960 outpatient diagnosis certificates were assessed, of which 78 had unclear address writing, accounting for 8%. 6 had age discrepancies with the electronic version, 16 had non capitalized numbers, 15 had stubs that did not match the electronic version, and 4 had diagnostic questions. Two diagnoses did not match the electronic records, 357 had electronic medical records, accounting for 37.2%. 142 medical orders were processed, accounting for 33.4%, 321 prescriptions were processed, accounting for 33.3%, and 278 examinations and tests were processed, accounting for 30%. 294 hard copy diagnosis certificate.
Conclusion  : The development of an outpatient diagnosis book management system can promptly screen out electronic and paper diagnosis books that do not meet the standards.