关于病案质量控制几个问题的思考  

Quality of Management of Case Book

作　　者：姚远[1] 王国祝 陈月 黄雅芳 祝秀都[4] 

机构地区：[1]解放军第205医院,锦州市121001 [2]内蒙乌兰浩特市医院,乌兰浩特市014000 [3]上海医科大学金山医院,上海200000 [4]上海医科大学妇产科医院,上海200000

出　　处：《中国医院管理》2000年第6期40-41,共2页Chinese Hospital Management

摘　　要：从目前病案质量控制的方法、过程和效果来看,出现了一种背离医疗质量的倾向。存在质控方法不当,表面化、形式化,弄虚作假,职责不清,奖罚不力,行政误导等问题。本文从完整病案质控机制,提高病案质控效能的目的出发,在提出上述问题的同时,分析了问题产生的原因,并提出:变终末质控为事前、事中质控,抓好全程、全员质量教育,实行责、权、利明晰的病案质控逐级负责制,改变修改方式,坚持正确的卫生行政导向,认真落实各项病案质控制度六点改进意见。Case book, from first to last page, in content, form, and style, should: possess strict serious, conscientious, scientific nature rather than superficial, mere formalities; reflect about natural history of disease and about how medical and surgical intervention can alter it beneficially or with possible side effects; facilitate to analyse different mechanisms of action, different profiles of interaction, relative advantages in procedures and therapies; record the clinial protocol, including details of operative techniques and treatments used; include detailed accounts if new procedures or modification of existing procedures have been employed, to make comparisons with those already conventionally used.

关 键 词：病案管理 质量控制 环节质量 终末质量 医院管理 

分 类 号：R197.3[医药卫生—卫生事业管理]