落实多层次质控提升病案质量  

Improve the Quality of Medical Records by Taking Multiple Effective Measures

作　　者：陆标明[1] 梁芳[1] 夏换兰 

机构地区：[1]广东省佛山市中医院三水医院,佛山市528100 [2]广东省佛山市三水区疾病防治所,佛山市528100

出　　处：《中国病案》2013年第2期23-25,共3页Chinese Medical Record

摘　　要：目的通过探讨病案质控的措施,提高医院病案质量。方法回顾性分析病案质控管理中的实践体会,建立符合标准化、科学化、系统化的五级综合质控管理体系,通过加强运行病历监控考核、归档病案的终末质控,落实多层次的有效监控措施,并建立激励机制。结果杜绝了丙级病历,病案质量得到整体提高,同时内涵质量也得到同步提高。结论建立五级质控体系,落实多层次质控措施是有效提升住院病案质量的途径。Objective To improve the quality of medical records by investigating effective measures of quality control. Methods To establish a standardized, scientific and systematic five levels quality control management system by retrospectively analyzing the prac- tice experience. Through, strengthening the medical record operation monitoring assessment and examination of terminal medical records, we can take multiple effective measures to achieve multi-level monitoring control and establish incentive mechanism at the same time. Result Eliminate the C-level medical records, and improve the overall quality of medical records as well as the connotation quality. Conclusions With the establishment of five levels quality control management system and the carting out of multiple effective measures in quality control, the quality of medical records was improved effectively.

关 键 词：病案 质控 体系 方式 

分 类 号：R197.3[医药卫生—卫生事业管理]