加强病案质量管理 提高病案内涵质量  

Strengthen Medical Record Quality Management and Improve the Quality of Medical Record Content

作　　者：许剑峰[1] 金玉[1] 孙明[1] 

机构地区：[1]中国人民解放军白求恩国际和平医院质量管理科,石家庄市050082

出　　处：《中国病案》2015年第4期28-30,37,共4页Chinese Medical Record

摘　　要：在病案形成过程中对存在的问题进行分析,有针对性地提出解决办法,落实相关措施,提高病案质量,确保病案内容真实可靠,是病案管理工作的重中之重。通过严格落实《病案管理规定》、狠抓质量缺陷源头,落实环节与终末相结合质控机制、开展病案质量网上展览和建立严格规范的病案修改审批制度及奖惩措施等,提高了病历书写过程中的医务人员病历书写水平和管理意识,使出院归档病案质量有了显著的提高。Analyze existing problems, put forward some solutions, carry out the relevant measures, improve the quality of medical record, and ensure the medical record is reliable, is the key of the medical record management. We should strictly implement the medical record management stipulation, find the quality defect source, implement link and terminal quality control mechanism, carry out the medical record quality online exhibitions and establish a strict medical record amend approval system and rewards and punishments measures, improve the level of medical record writing of the medical staff and management consciousness, make the hospital archive medical record quality improve significantly.

关 键 词：病案管理 环节质控 终末质控 病案展览 

分 类 号：R197.32[医药卫生—卫生事业管理]