病案质量考核活动期间存在的问题与措施  

Problems Existing in the Activity Period of Medical Records Quality Examination and Countermeasures

作　　者：胡桂周[1,2] 刘立新[1,2] 易薇[2] 谭伟潮[2] 冯伟民[2] 周洪波[2] 

机构地区：[1]南方医科大学中西医结合医院 [2]南方医科大学南方医院,广州市510515

出　　处：《中国病案》2014年第10期32-33,共2页Chinese Medical Record

摘　　要：为了更好地提高病案管理质量,保障医疗安全,防范医疗纠纷,医院每年定期开展病案质量考核活动,从每个科室抽取一定数量的病案,以科室为单位,统计和排列病案质量优、中、差的科室,既可发现病案管理工作中存在的不足,又能检测组织活动过程中出现的问题,并逐一采取相对应的措施加以解决。以此引起科室重视,提高医护人员病案质量意识,避免发生走过场、走后门等现象。In order to improve the management quality of medical records, guarantee the security of medical treatment and prevent medical disputes, our hospital carried out quality examination activity of medical records regularly every year so as to find defects in the management work and problems existing in the activity process of the organization. To select several cases of medical records from each department, take each department as a unit to make statistical arrangement on the quality of medical records with excellent, middle and bed three grades, so as to catch the attention of the departments, improve the quality awareness of medical staff and intensify supervision system of medical records quality. The phenomena of formalism thoughts were found in some department staff through the carrying out quality examination activity of medical records. Aimed at the problems existing in the examination activity of medical records, we should solve it with relevant measures and rethink the cause reasons, so as to improve the quality of medical records as well as the quality awareness of medical staff.

关 键 词：医疗质量 考核 活动 

分 类 号：R197.323[医药卫生—卫生事业管理]