病案存在问题分析  

An Analysis and Discussion about Problems in Medical Records

作　　者：魏丽娜[1] 廖红英[1] 欧阳菊香[1] 梁一霞[1] 

机构地区：[1]广东省佛山市第一人民医院,佛山市528000

出　　处：《中国病案》2007年第10期16-16,共1页Chinese Medical Record

摘　　要：目的通过对病案初步质控,找出病案存在问题,希望临床医生切实提高医疗安全意识,规范医疗行为,规范医疗文书记录,加强环节质量控制。方法对病案存在问题进行总结分析,提出可行的措施和建议。结果由于存在问题的及时反馈,为医疗质量的提高起到良好的促进作用。结论以实事求是的科学态度对待存在问题,不断总结经验,才能确保医疗质量的全面提高,尽量减少不必要的医疗纠纷。Objective To help doctors intensify their medical security consciousness, standardize their medical activity and documents, and strengthen the process of quality control we carried out the primary quality control of medical records, and found out the problems in the medical records. Method We summarized and analyzed the problems in medical records, and put forward practical measures and suggestions. Results Since the problems were timely reflected, the medical quality was improved. Condusions Only by seeking truth from facts and summing up experiences we can insure the medical quality improved and medical disputes have been reduced.

关 键 词：病案 问题分析 

分 类 号：R197.323[医药卫生—卫生事业管理]