病案内涵质量的管理与监控  

MANAGEMENT AND MONITORING OF THE CONNOTATION OF MEDICAL RECORDS

作　　者：张衍[1] 

机构地区：[1]广东医学院第二附属医院,广东湛江524003

出　　处：《现代医院》2005年第7期126-127,共2页Modern Hospitals

摘　　要：病案质量包括规范格式的外在质量和反映医疗质量的内涵质量,外在质量是基础,内涵质量是关键,是医疗机构综合实力的体现。提出必须建立一套病案质量管理模式,制定一套计划、标准、采取相应的措施加强质量监控,进一步提高病案质量。The quality of medical record includes outside standard format and content quality reflecting medical work. The exterior quality is base and content quality is key, which reflects the level of medical organization's synthetical ability. We must build up a model form of internal quality of medical record, and make a plan or standard format. We can take appropriate measures enhancing quality control and we can improve quality of medical record.

关 键 词：病案管理 医院管理 质量监控 病案质量 书写规范 

分 类 号：R197.323[医药卫生—卫生事业管理]