现阶段病案质量存在问题分析与对策  

An Analysis on the Existed Problems of the Quality of the Medical Records and the Countermeasures

作　　者：赵来嫦[1] 陈卫华[1] 

机构地区：[1]广东省肇庆市第一人民医院病案室,肇庆市526021

出　　处：《中国病案》2008年第5期17-19,共3页Chinese Medical Record

摘　　要：目的为了提高病案质量水平,探讨我院现阶段病案质量存在问题,提出改进措施。方法参照《广东省病案书写规范》,从日常病案质控工作中总结分析病案质量存在问题。结果病案质量存在多方面问题。结论要制定健全的病案质量监控制度,落实严格有效的管理措施,以提高病案质量。Objective To improve the quality of the medical record, explore the problems of the medical records in documentation, and then advance the measures of improvement. Method According to The Criterion of the Documentation of the Medical Record in Guangdong Province, we summed up and analyzed the problems in the quality of the medical record documentation, from the daily work of the medical records. Result We found that the quality of the medical record is in trouble in many aspects. Conclusion We must draw up sound supervision system, and carry out strictly and validly managing measure to improve the quality of medical record.

关 键 词：病案质量 问题分析 对策 

分 类 号：R197.3[医药卫生—卫生事业管理]