病案首页质量分析及控制措施  

Quality Analysis and Control Measures of the Front Sheet of Medical Records

作　　者：敬思猛[1] 宋桂花[1] 王养社[1] 杨雪莲[1] 李小兰[1] 

机构地区：[1]甘肃省酒泉市解放军第25医院信息科

出　　处：《中国病案》2011年第4期17-18,共2页Chinese Medical Record

摘　　要：目的针对病案首页填写缺陷,制定质量监控和改进措施。方法通过质量控制检查部门的检查修改和定期反馈检查,分析首页缺陷原因,提出改进措施并跟踪改进效果。结果病案首页缺陷明显减少,无缺陷病案首页从零提高到39.3%。结论提高病案首页填写质量,必须持之以恒地加强病案质量管理,必须增强医护人员的责任心,提高临床医师的业务素质。Objective Through making quality control and improvement measures to reduce fill-in defects of the front sheet of medical record.Methods After inspecting and regular feedback checking,the quality control departments analyze the defects reasons of the front sheet of medical record,and suggest improvement measures and track improving effect.Results The defects of the front sheet of medical record reduced significantly,the front sheet of medical record which has no defects increased from 0% to 39.3%.Conclusion We should strengthen quality management of medical records constantly,enhance the responsibility of health care workers,and improve the professional quality of the clinician to improve the front sheet of medical record fill in quality.

关 键 词：病案首页 质量分析 控制措施 

分 类 号：R197.3[医药卫生—卫生事业管理]