北京协和医院四级病案质量管理监控方法  

Quality Assurance of the Medical Record in Four Levels in Peking Union Medical College (PUMC) Hospital

作　　者：赵轶超[1] 刘爱民[1] 李杰[1] 

机构地区：[1]北京协和医院病案科,北京市100730

出　　处：《中国病案》2007年第7期4-6,共3页Chinese Medical Record

摘　　要：在新医疗管理模式下病案管理出现的新特点,北京协和医院为了保证病案质量,坚持实行病案四级质量管理监控方法,取得了较好的效果。一级质控是指经治的主治医师质控,在病人出院前,主治医师要完成病案书写,并全面检查病案的质量及签字。一级质控是北京协和医院自1921年建院以后的传统;二级指控是指病案出科前由科里的质控医师监控;三级监控是指医务处综合质量管理,四级监控是指病案室的终末质量管理。New characters of medical record information management have appeared for the service of medical legal and insurance as well as hospital management. In order to promote the quality of medical record content, PUMC hospital insists on the fourth steps records auditing. Attending physicians review all discharged patients＇ records before signature; designated doctor who is responsible for quality assurance in his/her word checks the completeness of records; Doctor from Medical affairs division reviews records comprehensively and the quality auditor from medical record department is responsible for record deficiency checking in final.

关 键 词：病案 质量 监控方法 

分 类 号：R197.3[医药卫生—卫生事业管理]