摘要
目的通过对病案终末质量监控,提高病案书写质量,同时提高医院管理水平。方法根据卫生部《病历基本书写规范》和《江苏省住院病历质量判定标准[2009年版]》,对近3年出院病案进行质量评定。结果 34,251份病案中有5154份存在缺陷,缺陷率15.0%。结论加强医务人员的法律意识和责任心,强化病历书写规范,提高病案书写质量和管理水平。
Objectives Through final quality monitor to medical records it improves writing quality of medical records and management level of hospital as well.Methods According to Basic Writing Norms of Medical Records and Quality Criterion Standard of Hospitalization Medical Records of Jiangsu Province[2009 Edition]of Ministry of Health,this article had a quality evaluation on hospitalization medical records in recent 3 years.Results There are 5154 medical records in 34251 ones have defects;the defects rate is 15.0%.Conclusions It suggests that should strengthen law consciousness and responsibility of medical staffs and writing standard of medical records,improving writing quality and management level of medical records.
出处
《中国病案》
2011年第7期21-22,共2页
Chinese Medical Record
关键词
病案缺陷
病案质量
医院管理
Defects of medical records
Quality of medical records
Hospital management
