转变病案质量控制模式 切实提高病案内涵质量  

Transform the Pattern of Medical Records Quality Control to Improve Internal Quality of Medical Records

作　　者：牟淑玲[1] 

机构地区：[1]山东省日照市中医医院质控科

出　　处：《中国病案》2009年第9期15-16,共2页Chinese Medical Record

摘　　要：目的探讨病案质量控制模式的转变对病案内涵质量的提高及医疗纠纷的防范的重要作用。方法采用积极有效沟通、管理互动,科室横向联合,建立二级纵向质控组织框架等综合的措施,对病案质量进行控制。结果病历缺陷率从27.7%降至13.14%。结论病案质量控制综合模式,能形成管理合力,构建交叉的有学术价值的质控评价体系,最大限度的提高病案书写质量从而提高病案质量管理水平。Objective To explore the important role of transformation of pattern of medical records quality control in the improvement of internal quality of medical records and prevention of medical disputes. Method Through applying comprehensive measures, such as active and effective communication, interactive management, horizontal integration of departments and establishment of secondary vertical frame of quality control organization, to control the quality of medical records. Result The defective ratio of 38416 cases has decreased from 27.7% to 13.14%, which means to the responsibility of quality control was performed quite well. Conclusion The comprehensive model of medical records quality control can form management resultant force, construct crossed quality evaluation system with academic value and improve quality of medical records writing to the greatest extent to enhance management level of quality of medical records.

关 键 词：病案 质量控制 管理互动 横向联合 内涵质量 

分 类 号：R197.3[医药卫生—卫生事业管理]