2007～2009年病历档案质量分析  

Analysis on quality of medical record from 2007 to 2009

作　　者：曾小军[1] 

机构地区：[1]广东省惠州市中心人民医院,广东惠州516001

出　　处：《中国医药导报》2011年第5期124-125,共2页China Medical Herald

摘　　要：目的：提高医务人员对病历档案书写的责任意识,增强法律、病历档案证据意识,防范医疗纠纷。方法：对我院2007~2009年归档病历档案逐份进行终末质量检查。结果：对存在质量问题的缺陷病历档案及时通知科室负责人返修整改,保证了归档病历档案质量。结论：通过对归档病历档案的终末质控,将结果进行归纳分析并采取整改措施,提高了病历档案质量。Objective： In order to improve medical staffs＇ consciousness of responsibility on medical record writing,and to strengthen the consciousness of laws and evidences.Methods： Terminal quality Inspection was taken for all the medical records from 2007 to 2009.Results： Informing the department director timely about the error medical record to vouch for the quality.Conclusion： It can improve the quality of medical records by the terminal quality control of medical record and the analysis and rectification measures for the error records.

关 键 词：病历档案书写 质量分析 意识 

分 类 号：G472.4[文化科学—教育学]