How to take into account the quality and efficiency of medical records?
Written text | Guo Xuemei
Writing of medical checks, probably is probablyEvery clinician can have a headache.
Ding Rui, deputy chief physician of the liver disease center of Beijing Diquan Hospital, remembers that when he became a doctor, he "planted the follower" on the medical records -EssenceYou know, for some drugs, the difference in the word in the name may be very different.
Fortunately, Ding Rui discovered and revised this error in time, "If there are too many typos, the superior also wants to throw it off when I look at my medical records."The error may also put doctors in an unfavorable situation -some studies have shown that the writing of medical records is not standardized, etc., which is one of the main reasons for the defeat of traditional Chinese medicine in the case of medical damage liability disputes.
Ding Rui is writing medical records
Actually, many clinical clinicals including Ding RuiDoctors are not sloppy. In the limited time of the patients many clinical diagnosis and treatment, they want to write a medical record that standardizes the use of medical terms with accurate expressions, smooth sentences, and correct punctuation, which is indeed difficult.
Even in the era of electronics, the phenomenon of inaccurate writing and irregularities often occur. Doctors complain that the text input method in the computer is difficult to adapt to the characteristics of medical work.I often "dig a pit" for myself, or I cant find accurate medical terms to turn a few pages, which greatly reduces writing efficiency, and also pose a potential threat to medical quality and patient safety.
For this reason, Sogou input method is closed with the National Infectious Disease Medical Center (Beijing) to launch Sogou input legal medical version, and is committed to solving the whole countryDoctors medical records.
Clinician, has been trapped in medical records for a long time
Medical records as important medical activity records for patients,It has its particularity and importance.In 2001, my country began to implement electronic medical records, and then after "electronic medical records", "popularization" of electronic medical records, and "systematic" electronic medical records.
In the view of the clinicians such as Ding Rui, although the electronic medical records are much more convenient, it is still very time -consuming during the computer input process.
She introduced to the "medical community". Usually, after patients were admitted to the hospital, doctors should complete the two major medical records of "admission records" and "first disease records"."Among the admission records, one of the longest history can be written to two pages, which consumes more energy and time. In the first disease record, the diagnosis of disease is more time -consuming."
Although writing medical records is a must for clinicians to improve professional technical literacy, many doctors hope that on the basis of ensuring the quality of medical records, can the writing time be shorter?Can efficiency be improved?After all, every minute is saved, doctors can allocate more to patients for one minute.
Doctor writes medical records/source source: Rui Jing
For this, national infectious disease medicine medicineLi Bing, director of the Central Office (Beijing) Office, was very touching.He told the "medical community" that in addition to the length of time, the medical records were actually quite complicated, which may involve Chinese, English, Latin and other languages, including various symbols such as submission, lowering, and even need to go back and forth between multiple input methods.Switching, "Medical proprietary vocabulary is extremely complicated, and it also makes the medical record writing task heavier."Not only these, in the process of writing medical records in clinicians, patients must be recorded at any time at any time.Indications, contraindications, etc., such as whether the indication is in line with medical insurance reimbursement standards.Sometimes, precautions need to be written on the medical records.
According to the "Basic Specifications for Writing Medical Revices" issued by the Ministry of Health in 2010, doctors usually need to write the door (urgent) diagnosis and hospitalization medical records.
Taking the hospital for hospitalization as an example, including the homepage of the hospital, admission records, course records, surgery consent, anesthesia consent, etc., all need to be completed by the doctor.Data show that in general, a clinician of the Department of Inpatient is responsible for 5-10 patients every day, and spends daily spending on medical records for 3-6 hours.
As a medical activity record, medical records are also an important legal basis.In real life, many medical institutions have irregular medical records, so that they have defeated in medical disputes.According to statistics from the "Medical Law", in 2023 national medical damage liability dispute cases, the proportion of cases affected by the proportion of medical responsibility due to irregular medical records accounted for 41.94%.
Therefore, even the factors related to the writing of medical records, even an input method software, will affect the work efficiency of doctors, and even allow doctors and hospitals to avoid medical proceedings.
"The writing of medical records is an indispensable training in the growth of doctors." Ding Rui believes that the medical record is a record and summary of the patients condition, and one of the basic ability of the doctor. "We usually dont think it is a burden, but if the time is too long, or the usual work is busy, it will be relatively impatient in the writing of the medical records.Save the time to use doctors to write medical records, communicate with patients, or pay attention to the diagnosis and treatment of the disease itself, and return the doctors time to the patient. This will greatly improve the doctor -patient relationship and improve the work efficiency of the doctor.
What is a good medical record writing tool?
For the problem of medical records, Li Bing also felt the same when doing clinicians.After becoming a hospital manager, he has been thinking about how to improve this issue.In 2023, he took the initiative to throw olive branches at a number of manufacturers, hoping to cooperate with professional institutions to respond to the general demands of doctors.
He recalled to the "medical world" that the development of medical record writing tools is relatively unpopular and very professional field.Third -party institutions are not easy.
Among them, the Tencent Sogou input method responded to Li Bing first.When talking about the cooperation, the other party sent him several successful cases, which brought new inspiration to Li Bing.In fact, the Sogou input method team began to intervene in the development of the population in the vertical field very early. In 2018, it also launched the Sogou Input Dr. Dr. Edition.
"We have deeply optimized the original thesaurus of the original medical industry through in -depth exchanges with the first -line clinicians, and updated the data of the State Health and Health Commission and the State Medical Insurance Bureau.It is based on cooperation with the National Infectious Diseases Medical Center (Beijing), and the medical records of many experts have been built into the input method.
Use Tencent Sogou input legal medical records to write hospitalization medical records
, Tencent Sogou Entering the Legal Medical Edition for a year, and took the lead in launching testing at the National Infectious Disease Medical Center (Beijing), that is, Beijing Tanzan Hospital affiliated to the Capital Medical University.During the cooperation process, the Sogou Input Method Team is responsible for providing technology, while Beijing Diquan Hospital provides specific medical record data.
"This is a very large project, which is like the most consuming decoration time is underground project." Li Bing introduced that during the research and development process, clinicians at Beijing Earth Altar Hospital didA large number of standardized work is to turn some daily medical records to a template that can be used for others to learn from.
For example, a popular cold, doctors need to diagnose common diseases into a standardized text, "Even some complex symbols in the physical examination, Latin text, English in the test form, English, English, EnglishRune also needs to be sorted into data.
Ding Rui is one of the first doctors who tried the product. She introduced to the "medical industry". Before the Tencent Sogou enters the legal version, she usually needs to complete a record of admission.30 minutes to 1 hour, the first disease record is also about 30 minutes.The time after use is greatly shortened, "It only takes 13 minutes to write a record of admission now."
"The most intuitive experience is that I dont need to choose words, especially someThe name or medicine name of the disease or medicine, medical symbols, I dont need to find them one by one, and the efficiency of the medical records can be improved.A "medical record assistant" module is set up to provide doctors with some examples of medical records that can be imitated.If there is a demand, doctors can even combine demonstration of medical records and build templates according to their own needs.
"Now we have been spread out in nearly six or seven departments, there are about 70 diseases. Through calculation, with the help of Tencent Sogou to enter the legal version, a doctor in our hospital is in the hospital.The writing of medical records can save about 40%. "Li Bing told the" medical world ".
Reduce the burden on the grassroots medical institutAt the Academic Conference of the Medical Center (Beijing) Infectious Diseases Specialized Alliance and the Fourth Dean Alliance, Tencent Sogou Input Law officially announced a cooperation with the National Infectious Disease Medical Center (Beijing) to jointly release the "Tencent Sogou input legal medical version", Dedicated to solving the problem of medical records of doctors across the country.
After trying the Tencent Sogou input legal medical version, Ding Rui and other doctors are very helpful.
However, considering that medicine is a continuous development subject, each disease will regularly update consensus, guidelines, drug directory, medical insurance directory, etc.In the future, the latest progress and clinical specifications in the medical field can also be included in the input method.
"Tencent Sogou Input Legal Medical Edition" is officially released
Doctors learn the tools for new knowledge.You can also learn new knowledge, "This is a more rare thing."
In the past, at the hospital, information systems, drug use systems, medical insurance systems, electronic medical records, etc.It is separated and the management is very heavy.As a hospital manager, Li Bing believes that the input method can try to connect these information systems through technology in the future to achieve resource integration.
"We want to use cooperation with Beijing Diquan Hospital to reduce the burden on more grassroots medical institutions." Gu Haiboli said.Survey data show that in our country, grass -roots medical institutions such as clinics, health centers, etc. are usually part of the irregular subjects of medical records.
At present, in addition to the medical records related to infectious diseases, Tencent Sogou also established a medical record of nearly a thousand common disease experts, which can meet the needs of comprehensive hospitals.
"In the past investigations, we found that even if many grass -roots doctors were trained, it would be difficultBy the time some difficult cases, they usually hope to get the guidance of higher -level doctors.Clinical product services, such as treatment plan recommendations, medication instructions, and case case libraries for difficult diseases, etc., so that first -tier clinicians can obtain information more quickly, realize self -learning, and further improve clinical efficiency and quality.
*"Medical" strives to make the content of the content and reliability, but not promise the accuracy of the content;Essence
