重新设计数据处理工作流程以自动化缩写 临床文档审计
Bee Keow Goh1, Galvin Gan1, Mark Chuah1
1KK Women's & Children's Hospital, Singapore.
Studies in health technology and informatics
|January 25, 2024
概括
在KK妇女和儿童医院 (KKH) 对临床病例笔记的审计现在使用过程再工程和Excel应用程序. 这提高了审计覆盖范围,减少了错误,并通过尽量减少批准的缩写的手动引用来节省时间.
科学领域:
- 医疗保健管理部门的管理.
- 改善临床文档的改善
- 医疗信息学 医疗信息学
背景情况:
- 临床病例笔记的季度审计在KK妇女和儿童医院 (KKH) 进行,以确保遵守批准的缩写使用.
- 目前的审计过程是手动的,包括检索纸质和电子案例笔记,以参考临床编码人员批准的缩写列表.
- 这种手动方法耗时,容易出现人为错误,可能会限制审计覆盖范围.
研究的目的:
- 重新设计临床病例笔记审计流程,以提高效率和准确性.
- 利用技术,特别是Excel应用程序,简化已批准的缩写的引用.
- 扩大审计覆盖范围,同时减少对人工人力资源的依赖,并尽量减少错误.
主要方法:
- 实施过程再工程原理,重新设计审计工作流程.
- 开发和使用自定义的Excel应用程序,以自动化缩写的交叉引用.
- 整合电子和纸质案例笔记检索功能,以获取全面的审计数据.
主要成果:
- 显著减少人类依赖于引用批准的缩写.
- 证明了与手动缩写检查相关的错误减少.
- 在现有审计周期内实现的审计覆盖范围的扩大.
- 在进行临床病例笔记审计所花费的时间上节省了大量的时间.
结论:
- 流程再工程与Excel应用程序相结合,为优化临床病例笔记审计提供了有效的解决方案.
- 修订后的流程加强了批准的缩写使用的合规监测.
- 这种技术整合可以提高医疗保健文档审计的效率,准确性和资源分配.
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