摘要
目的了解临床科室病历书写质量存在问题的主要因素及质量控制在病历书写中的重要作用。方法根据中国病案管理专业委员会《住院病历质量检查评价标准》的要求对抽取的病案进行评价、分析。结果质控后病案缺陷数和病案首页、病程记录、出院记录、手术相关记录、检查报告单、护理文书的缺陷率较质控前明显减少。结论病案管理是一项需要长期、持久、有计划的管理,一刻都不能松懈,必须建立一套严格的质量管理机制,才能取得良好的成效。
Objective To know about the main factors affect writing quality of medical record and the important role of quality control in medical record writing.Methods According to Quality Examination and Evaluation Standard of Medical Record of Chinese Medical Record Association,medical record been selected are evaluated and analyzed.Results After quality control,the number of medical record defeat and the defeat rate of front page,course of disease record,hospitalization record,operation record,examination report,and nursing record reduce obviously after quality control.Conclusions Medical record management is a long-term,permanent and planed work that can not be relax.It needs to set up a strict quality management mechanism for it to get good effect.
出处
《中国病案》
2011年第5期25-25,21,共2页
Chinese Medical Record
关键词
病案质量
质量控制
对比分析
Medical record quality
Quality control
Comparative analysis
