医疗保险病案书写质量的缺陷与防范  

Defects in the Quality of Medical Records Writing for Medical Insurance and the Countermeasures

作　　者：边连朵[1] 刘海燕[1] 

机构地区：[1]首都医科大学附属北京安贞医院,北京市100029

出　　处：《中国病案》2010年第4期21-23,共3页Chinese Medical Record

摘　　要：目的了解医保病历书写质量现状,探讨医保病案质量控制的重点。方法检查并分析某三甲医院2006年-2008年医保拒付病案。结果医保拒付病案普遍存在因书写不规范而引起拒付的问题。平均缺陷率为50.5%。结论通过加强病历书写知识和医保制度培训,可以提高医师对医保制度的认识和病历书写的专业水平。Objective To understand the status of the quality of medical records writing for medical insurance and to explore the key points of quality control of it.Methods All of medical records for protest in medical insurance in a third-class A-grade hospital from 2006 to 2008 were studied and analyzed according to the standard of ＂Specification for Medical Records Writing＂.Results Non-standard medical records writing for medical insurance was found commonly,which resulted in the protest in medical insurance.The mean rate of defect was 50.5%.Conclusions It is necessary to strengthen the training in writing medical records and medical insurance rules for physicians,so as to enhance the consciousness of complying with medical insurance rules and quality of medical records writing.

关 键 词：病案 质量控制 医疗保险 

分 类 号：R197.3[医药卫生—卫生事业管理]