构建病历质控体系 提高病历质量  

Construction of Medical Records Quality Control System to Improve the Quality of Medical Records

作　　者：谢小燕[1] 罗胜[1] 杨洪涛[1] 王胜南[1] 

机构地区：[1]第三军医大学西南医院,重庆400038

出　　处：《中国卫生质量管理》2013年第5期1-4,共4页Chinese Health Quality Management

摘　　要：以科室质量管理小组自控、住院总医师监控、质控科专职人员网上实时监控、职能科室联合现场督查等开展住院病历质控;以兼职专家监控、病历质控专家委员会监控与评定开展出院病历质控;以质量分析、质量讲评、培训与业务查房、效果追踪等促进病历质量持续改进。形成了多元化、规范化、标准化、制度化的病历质控体系,有效提高了病历质量。The quality control of inpatients medical records was carried out through self - control by department quality management team, chief resident monitoring, online real -time monitoring by quality control division dedicated staff, jointly site supervision by functional departments; the quality control of medical records of discharged patients was carried out through part - time expert monitoring, monitoring and assessing by the Committee of Experts on medical records quality control; the quality analysis, quality comments, training and business rounds, and tracking results was used to promote continuous improvement of quality of medical records. A diversified, standardization and institutionalization of medical quality control management system was formed to improve the quality of medical records.

关 键 词：病历 质量 质控体系 提高 

分 类 号：R197.32[医药卫生—卫生事业管理]