the national health commission issued a document, new regulations for outpatient (emergency) treatment information registration →
2024-09-12
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according to the national health commission on september 9, the national health commission recently issued the "regulations on quality management of outpatient (emergency) treatment information pages (trial)" (hereinafter referred to as the "regulations"), aiming to further strengthen medical quality management, do a good job in outpatient (emergency) related information collection, and consolidate the data foundation of medical management work. the "regulations" will come into effect on november 1, 2024.
the outpatient (emergency) medical treatment information page referred to in the regulations is a summary of the patient's medical treatment process, which is formed by the hospital based on the outpatient (emergency) medical records and various information generated during the patient's outpatient (emergency) medical treatment in this hospital, including basic patient information, medical treatment process information, medical treatment information, and cost information. the information page is not included in the outpatient (emergency) medical records, and is saved by the hospital in an appropriate form such as an electronic data set or electronic document according to the actual situation.
the regulations mainly include three aspects: first, it clarifies that medical institutions should timely summarize and preserve 72 items of outpatient (emergency) diagnosis and treatment information in four categories, including basic patient information, medical process information, diagnosis and treatment information, and cost information. second, it clarifies the specific content, collection and preservation requirements of relevant information items, and formulates relevant information quality and interface standards to ensure that information data is standardized and available. third, it provides guidance on the use of relevant information by medical institutions to carry out quality control work, and promotes hospitals to continuously improve outpatient (emergency) management and diagnosis and treatment quality.
the national health commission requires that hospitals of all levels and types should correctly understand the requirements of the regulations, combine the actual work of the hospital, and use information technology to collect, save, analyze and feedback relevant information to promote the improvement of outpatient (emergency) diagnosis and treatment quality. information items that cannot be collected by the hospital through information technology will not be included in the summary for the time being. medical staff shall not be required to add additional writing tasks on the grounds of the regulations, which will increase the burden on frontline medical staff.
ni shixuan, reporter of nanfang.com and yuexuexue
