N-VýN-S;ƒoOá`o[fO VâOShQÆ N-VýN-S;ƒoOá`o[fO VâOShQÆ N-VýN-S;ƒoOá`o[fO VâOShQÆICS35.240.80 团 体 标 准 T/CIATCM 079 —2020 中医住院电子病历数据质量控制标准 Criteria for data quality control in inpatient electronic medical records in Tradtional Chinese Medicine 2020 -10- 15发布 2020- 10-31实施 中国中医药信息学会 发 布 全国团体标准信息平台 N-VýN-S;ƒoOá`o[fO VâOShQÆ N-VýN-S;ƒoOá`o[fO VâOShQÆ N-VýN-S;ƒoOá`o[fO VâOShQÆT/CIATCM 079—2020 1目   次 前言................................................................................................................................................................... ...2 1 范围 .................................................................................................................................................................... 3 2 规范性引用文件 ................................................................................................................................................ 3 3 术语和定义 ........................................................................................................................................................ 3 4 中医住院电子病历质量控制标准 ................................................................................................................... 4 4.1 中医住院电子病历质量控制体系 ........................................................................................................... 4 4.2 中医住院电子病历质量控制工作流程 ................................................................................................... 4 4.2.1 全院中医住院电子病历质量控制工作流程 ................................................................................... 4 4.2.2 临床科室中医住院电子病历质控工作流程 ................................................................................... 5 4.2.3 医疗质管办（组）中医住院电子病历质控工作流程 ................................................................... 5 4.2.4 病案质控小组中医住院电子病历质控工作流程 ........................................................................... 5 4.2.5 数据中心中医住院电子病历质控工作流程 ................................................................................... 5 4.3 中医住院电子病历质量控制要求 ........................................................................................................... 5 4.3.1 整体要求 ........................................................................................................................................... 5 4.3.2 完整性 ............................................................................................................................................... 6 4.3.3 一致性 ............................................................................................................................................... 6 4.3.4 准确性 ............................................................................................................................................... 6 4.3.5 及时性 ............................................................................................................................................... 6 5 中医住院电子病历首页数据质量评价标准 ................................................................................................... 6 5.1 首页数据质量评价标准概述 ................................................................................................................... 6 5.2 首页数据的质量分类规范 ....................................................................................................................... 6 5.3 首页数据质量评分标准 ........................................................................................................................... 7 5.4 首页数据质量评价表及说明 ................................................................................................................... 7 6 中医住院电子病历首页数据质量评定结果处理 ........................................................................................... 7 附录 A (规范性附录) ............................................................................................................................................ 8 附录 B (规范性附录) 中医住院电子病历首页质量评价标准 .....................................................................