四川大学华西医院规范日间手术病历书写的探索与实践  

Exploration and practice of the norm of medical records for day surgery in West China Hospital of Sichuan University

作　　者：帅冰星 李志超[2] 张晓蓉[2] 汪勇[1] 马洪升[2] 戴燕[2] 陈敏[1] 李大江[1] SHUAI Bingxing;LI Zhichao;ZHANG Xiaorong;WANG Yong;MA Hongsheng;DAI Yan;CHEN Min;LI Dajiang(Medical Affairs Department,West China Hospital,Sichuan University,Chengdu,Sichuan 610041,P.R.China;Day Surgery Center,West China Hospital,Sichuan University,Chengdu,Sichuan 610041,P.R.China)

机构地区：[1]四川大学华西医院医务部,成都610041 [2]四川大学华西医院日间服务中心,成都610041

出　　处：《华西医学》2019年第2期145-149,共5页West China Medical Journal

基　　金：国家自然科学基金(71804117);四川省科技厅科研课题(18RKX0513;2017ZR0056);四川省卫生和计划生育委员会科研课题(18PJ487;16PJ338)

摘　　要：日间手术模式的推广,改变了传统住院手术流程,并对医疗质量管理者提出了更高的要求。因此医疗机构需要有与其配套的医疗文书记录、管理规范。四川大学华西医院医务部、日间服务中心不断研究、探索适合日间手术模式诊疗特点的病历书写基本规范,以保证医疗质量、简化医疗文书的书写工作。四川大学华西医院日间手术病历书写的新规范不仅满足病历书写的基本要求,还进一步规定病历的内容细节,增加病历考核的评分细则等;而且,新的规范积极探索日间手术病历质量的管理模式,例如,通过院科两级管理模式,设置病历质量监控员岗位,调动临床科室、日间服务中心的工作积极性,来规范医务人员病历书写行为,从而保证病历质量。The promotion of day surgery has improved the procedure of the traditional inpatient surgery and put forward higher professional requirements for medical quality managers. Therefore, medical institutions need the matching norm of medical documents recording and management. The Medical Affairs Department and Day Surgery Center of West China Hospital of Sichuan University keep exploring and practicing new norm which should be conform with the diagnosis and treatment characteristics of the daytime operation mode to insure medical treatment quality and simplify the writing work of medical documents. This new recording norm of West China Hospital of Sichuan University for day surgery should not only meet the basic requirement of the medical record writing, but also stipulate the content detail and add more assessment rules for records grading. Moreover, the new norm could actively explore the management mode of medical record quality for day surgery. For example, by arranging the medical record quality monitors and arousing the working enthusiasm of clinical department and day surgery center through the(hospital and clinical departments) twolevel management mode, the medical record writing process could be normalized, and the quality of medical records could also be well guaranteed.

关 键 词：日间手术 病历书写 质量控制 管理规范 

分 类 号：R197.323[医药卫生—卫生事业管理]