检查与管理相结合提升病案质量  

Combination with Examination and Management to Enhance Medical Records Quality

作　　者：顾亚明[1] 杨引[1] 张冬玲[1] 季宝轶[1] 

机构地区：[1]南京医科大学附属南京儿童医院质管办,南京市210008

出　　处：《中国病案》2012年第11期18-20,共3页Chinese Medical Record

摘　　要：为提升我院医疗、病案质量水平,我院质量管理办公室自2010年通过定期检查归档病案,将存在缺陷汇总归类、反馈,并针对缺陷采取管理措施敦促整改。我们从管理入手,以核心制度和诊疗规范为基础,抓科主任考核,重视科室病案质控,加强对重点科室的监控,强化住院医师培训;开发和提升电子病历功能,出台科室劳务费与病案质量挂钩的分配政策,同时合理引进人才,降低工作强度。经过边检查,边反馈,边管理,边整改,2011年全院病案质量有所提高,检查与管理相结合对提升病案质量有良好的促进作用。In order to enhance the quality levels of medical record, quality management office in our hospital regularly check the archive medical records with dassification of the defects and feedback, for urging rectify and reform by implementation of management measures since 2010. Starting from the management, based on the core system and diagnosis and treatment norm, we focused on the assessment of director, medical record quality control, monitor on the key departments and the residency training strengthening; electronic medical records function was developed and improved. Re- ward for personal services was linked to medical records quality. We reasonably brought in talents and reduced working strength. Through examination- feedbeck-management-rectify and reform, the medical records quality of the whole hospital had improved since 2011. Therefore, the combination with examination and management plays better improvement role for improving medical records quality.

关 键 词：病案质量 医疗质量 检查 管理 

分 类 号：R197.3[医药卫生—卫生事业管理]