摘要
目的通过对病历质量缺陷及其成因的分析,探讨提高病历质量的对策措施。方法采用前瞻性的调查方法,随机抽取了我院2006年1～6月的在线电子病历共6 515份,抽检率占1～6个月全院总病历数的21．3％。按《病历书写基本规范》和《电子病历质控实施细则》的要求进行质控。结果从病历环节质量控制发现,在病历形成过程中部分内容记录不完整,导致病历的价值不能充分体现。结论建立有效的质量管理体系,加强对电子病历的环节质控,提高医务人员的整体素质,是全面提升病历质量和医疗质量的关键。
Objective To study the countermeasure improving electronic medical record quality after analyzing the causes of defects in the electronic medical records. Methods To extract 6 515 cases of online electronic medical records randomly from January to June in 2006 in a prospective research. The sampling inspection ratio was 21.3%. Quality control was performed according the Basic Standard of Medical Record Writing and Practice Regulation of Electronic Medical Record Quality Control. Results Imcomplete records in some medical records, which decreased the value of medical records, were found by medical record link quality control. Conclusion It is the key to improve medical record quality and medical quality to establishing the effective quality control system, strengthening the linkquality control of the electronic medical records and improving the whole quality of clinicians.
出处
《重庆医学》
CAS
CSCD
2007年第2期101-102,共2页
Chongqing medicine
关键词
病历质量
环节质控
在线病历
medical record quality
link quality control
on-line medical record
