摘要
目的完善病案质量控制体系,充分发挥群众的力量,提高病案质量,达到医院评审的要求,保障医疗安全。方法运用临床科室出院病案自评系统,对出院病案实施科级质控,持续改进病案质量。结果自2015年6月使用出院病案自评系统后,质控出院病案评分率由原来的10%提高到70%,甲级病案率有原来的85%提升到98%。结论出院病案质量自评系统的使用,使得参与质控的病案数量、比例和范围均有显著提高,消除丙级病案,出院病案的完整性、准确性、及时性明显提高,且呈现持续改进态势,为后续的医疗、病案复制等活动奠定坚实的基础。
Objective To improve the quality control system of medical records and enhance the quality of medical records through taking advantage of the hardworking of the mass staff,so as to reach the requirements of the hospital review and guarantee the safety of health care. Methods To conduct quality control on the discharged medical records in department level with the application of self evaluation system of discharged medical records,and improve the quality of medical records continuously. Results The score rate of quality control discharged medical records had increased from 10% to 70% since the application of self evaluation system of discharged medical records in June 2015,and the level A rate of medical records increased from 85% to 98%. Conclusions With the application of self evaluation system of discharged medical records,the quantity,proportion and range of medical records all had improved,Class C medical records had been eliminated,the integrity,accuracy and timeliness of the medical records were improved obviously,and had a tendency of increasing continuously,which would lay a solid foundation for the follow-up of medical records duplication and other activities.
出处
《中国病案》
2016年第9期18-20,共3页
Chinese Medical Record
关键词
出院病历
质量控制
自评系统
Discharged medical records
Quality controlling
Self evaluation system
