病历质控须从细处入手  

Quality Control of Medical Records should start with Details

作　　者：蔡青[1] 衡爱萍[1] 雷光文[1] 周玉萍[1] 

机构地区：[1]陕西宝鸡市解放军第三医院,宝鸡市721004

出　　处：《中国病案》2012年第1期13-14,共2页Chinese Medical Record

摘　　要：目的实现病历质量有效控制,提高病历内涵质量。方法健全规章制度,规范病历管理;从病历书写细处着眼,从点滴抓起,查找质量问题并及时解决;及时与医生沟通,减少认识偏差;注重病历内涵质量,掌控关键环节,有效监控运行病历,认真评审终末病历,实行奖优惩劣。结果通过病历质量控制,医院的病历书写更加严谨,医疗行为更加规范,病历质量缺陷发生率逐年下降,病历内涵质量明显提高,甲级率逐年上升达到96.8%,及时归档率达100%。结论病历质量控制并非一蹴而就,病历质量管理者要充分认识到病历质量控制的长期性、严谨性、全员性及创新性,只有日日抓、月月抓,持之以恒,才能见成效。Objectives to achieve effect control of medical records quality and to improve connotation quality of medical records.Methods This paper puts forwards methods for quality control as followings： perfection of rules and regulations and standardization of medical records management;starting with writing details of medical records,it finds out quality problems and solves timely;communication with doctors timely for reducing cognitive deviation; value on connotation quality of medical records,key segments control,effect control of running medical records,careful evaluation about final medical records and implement of reward for excellent and punishment for bad.Results Through quality control of medical records,the medical records writing of hospital become more rigorous and medical behavior become more standard;the rate of defects incidence of medical records quality decreases gradually;connotation quality of medical records improves obviously;the rate of class-A is up to 96.8%;the rate of timely filing is up to 100%.Conclusions The quality control of medical records cannot be done by one go.The manager of medical records quality should fully realize that the long-time,rigorous,all-related person and innovation of quality control become effective only in a persistent way through by day by.

关 键 词：病历 质量控制 方法 

分 类 号：R197.3[医药卫生—卫生事业管理]