病历内涵质量的标准化质控实践  

Practice on Standardized Quality Control of Medical Records Connotation Quality

作　　者：张文一[1] 刘月辉[1] 刘金马[1] 刘丽华[2] 

机构地区：[1]解放军总医院,北京100853 [2]解放军总医院医管所,北京100853

出　　处：《中国卫生质量管理》2016年第1期15-18,共4页Chinese Health Quality Management

基　　金：军队研究性医院创建模式研究(14CX2004)

摘　　要：目的通过建立标准化环节病历监控系统,实现医疗核心制度落实、并发症监测等病历内涵质量的监控与管理,形成系统化、标准化的医疗质量监测流程。方法建立环节质量监测指标、标准监测方法和监测流程,实施信息系统、专人专岗、全过程的监测。结果实现环节病历全方位、全过程质量监测,使得病历完整性、准确性、及时性得到了保证,问题病历率持续降低,医疗纠纷呈下降趋势。Objective To establish a standardized system of medical records monitoring system to achieve medical records connotation quality and management, including the implementation of medical core system, monitoring of complications, etc. , to establish the real - time systematization and standardization of medical quality monitoring processes. Method The quality monitoring index, the standard monitoring method and the monitoring procedure were established to implement monitoring with informatization system, specific post, and full processes. Result The full range and whole process monitoring of medical records was achieved, the completeness, accuracy and timeliness of medical records was ensured, which continuing decreased the rate of question medical records and medical disputes.

关 键 词：病历 内涵质量 质控专家 

分 类 号：R197.323[医药卫生—卫生事业管理]