加强病案规范管理 提高病案内涵质量  

Strengthening the Standardized Management to Improve the Content Quality of Medical Records

作　　者：陈爱娟[1] 卓安山[1] 

机构地区：[1]解放军第411医院质量控制科,上海市200081

出　　处：《中国病案》2010年第1期22-24,共3页Chinese Medical Record

摘　　要：病案是病人住院期间医疗活动的原始记录,是综合评价医院医疗质量、技术和管理水平的依据,也是依法执业、保护医患合法权益的最直接证据。因此,加强规范化管理,不断提高病案内涵质量和医疗质量,是医院赖以生存和发展的生命线。Medical records, the original record of patients＇ medical care during the hospitalization, is not only the basis for comprehensively evaluating the quality, technology and management of the hospital, but also the direct evidence for practicing medicine according to law and protecting the legal rights and interests of patients and doctors. Therefore, it is the survival and developmental lifehne that hospitals depend on to strengthen the stan- dardized management and improve the quality of medical records＇ content and medical care.

关 键 词：病案 内涵质量 管理 

分 类 号：R197.3[医药卫生—卫生事业管理]