病案终末监控的新模式  

A New Mode of Eventually Monitoring the Medical Record

作　　者：赵增虎[1] 范水平[1] 李永申[1] 张建宇[1] 闫淑英[1] 

机构地区：[1]解放军第251医院医务处,张家口市075000

出　　处：《中国病案》2006年第12期10-11,共2页Chinese Medical Record

摘　　要：目的探讨病案终末监控的新模式对病案质量的影响。方法每月抽查每位医师2～3份出院病案,结果汇总后反馈给经治医师进行自监,自监结果交回病案室计分。对分数有疑义者请多名专家复议,然后计分。最终得出病案质量和监控能力分数。结果病案质量得到了全面、客观、准确的监控,全员重视病案质量的意识也明显提高,甲级病案率达98．2％。结论病案终末监控的新模式对病案质量和监控能力的提高有很大影响。Objective To explore the effect of Eventually Monitoring the Medical Record on medical records quality. Method Every month we selectively exam two or three medical records of the discharged patients last month. Then the results were submitted to special messenger by the medical record library for gathering. After that, we return the gathered results to the attending physician for monitoring himself, and the results were presented back to medical record library again. Those undoubted records were scored, and the doubted were sent to several specialists for discussing and scoring. At last, we got the scores of the quality of the medical records and the scores of the monitor capability of the doctors. Results After the monitoring mode was applied, all medical records were monitored roundly, objectively and exactly. The staff＇s consciousness of medical record quality was raised obviously. At the same time, the first rate of medical records was top to 98.2%. Conclusion The monitor mode will bring about great effect on the medical records monitor.

关 键 词：信息化管理 终末病案 监控模式 

分 类 号：R197.3[医药卫生—卫生事业管理]