For medical institutions, medical record archives have its unique medical value and scientific research value; For the majority of patients, the medical record file is convenient for them to seek medical treatment, understand the condition in time, and effectively protect their own interests. The whole process tracing management of medical records is an inevitable trend of the development of medical record management in the information age and an important stage of medical record digitization. The whole process tracing management of medical records with RFID technology can not only realize a scientific and efficient management mode, It can also save human and material costs.
1、 RFID technology background
RFID technology is a comprehensive self identification technology based on carrier, coding, identification, communication and other technologies. RFID technology mainly uses the spatial coupling of RF signals to realize contactless information transmission. Different items can transmit different information, so as to achieve automatic identification. Compared with other similar technologies, RFID technology has the characteristics of large storage capacity, fast reading rate, long reading and writing distance, strong penetration, long service life and good environmental adaptability. The RFID system shall have three basic components, RFID tag, several RFID readers and background computer.
RFID tag adheres to the object and sends out RF signal. RFID reader realizes tag information collection and returns data. The read information is transmitted to the background computer, which analyzes the transmitted information and manages the normal operation of the whole tag system. RFID technology is applied to the medical record tracing system, mainly by pasting electronic labels on each medical record, installing readers at the use positions of clinical departments and various departments in the medical record room, and connecting the background computer with the port of the medical record tracing system. Medical record managers can accurately query the process and location of medical records and confirm the filing time through the tracing system.
2、 Application of RFID technology in tracing the whole process of medical records
2.1 medical record recovery
After the first level quality control of the Department, each medical record discharged from the Department on that day shall be uniformly sent to the medical record room by the property after the general affairs nurse pastes the RFID electronic tag. The medical records are sent to the medical record recovery room equipped with RFID reader. The medical record administrator registers the recovered medical records and compares them with the information of discharged patients on that day to obtain the list of unfilled medical records and the location of the Department where the medical records are located. After the recovery, the administrator can uniformly identify the medical record information in the medical record tracking system as the filing status.
2.2 disease code
After the recovery of medical records, the staff of the coding group shall carry out disease coding. An RFID reader is installed next to the office or office computer of the coding group. When the coder files the medical records to the workplace, the RFID reader can not only trace the medical records into the disease cataloging link, but also to the specific location. Through ID identification, the coder judges whether the medical records to be catalogued on that day have been filed in the medical record room, so as to effectively supervise the Department to file the medical records in time. After cataloging, the coder can uniformly identify the medical record status as coded status with one key.
2.3 medical record quality control
The coder shall hand over the coded medical records to the quality controller. The medical records pass through the quality control office equipped with a reader. The quality controller can first query whether the transferred medical records are consistent with the number of discharged medical records on the same day. If not, query the location and working status of the medical records through the tracer system, then carry out quality control on the medical records and identify the status information of the medical records.
2.4 medical record feedback
After the medical records are sorted and bound, some medical records need to be put into the feedback cabinet in the medical record reading room due to missing signatures, missing items and other reasons. The medical record administrator can form a circulation record of the feedback medical records through the RFID reader installed in the reading room. Since the feedback medical records need to be rectified by clinical medical personnel, they are easy to be taken to the reading room or even outside the medical record room. The medical record management personnel can feed back when the medical records are taken out of the reading room through background data monitoring, so as to find the whereabouts of the medical records.
2.5 circulation of medical records
Medical personnel in clinical departments and other medical technology departments borrow and return medical records. Through the unified identification of RFID on medical records, enter borrowing departments, borrowing personnel and relevant borrowing reasons, and the system automatically generates medical records borrowing and return records.
Responsible editor: CT