构建全方位病历质控体系  

Establishment of Multi- Faceted Quality Control System of Medical Records

作　　者：房洪军[1] 张渺[1] 孙璐[1] 刘辰龙[1] 付京波[1] 王平[1] 

机构地区：[1]北京大学第一医院,北京100034

出　　处：《中国卫生质量管理》2016年第2期36-38,共3页Chinese Health Quality Management

摘　　要：建立制度与技术层面的保障,并辅助绩效考核与培训等多重管理举措,从而达到界定不同部门与不同级别医师的职责,建立常态化、高水平的质控医师团队的目的,充分发挥信息化平台及其它沟通渠道的作用。全方位病历质控体系的构建保证了及时发布病历质控结果,实现了病历的全过程质控,使终末病历甲级率维持在较高水平。Through establishing the system and the technical level of measurements, accompanying with performance as- sessment and training, the targets of planning the duties of departments and different levels＇ physicians, and establishing normal- ized high level physician team of medical records quality control were achieved. Making full use of information platform and other methods, by releasing the quality control results of medical records promptly and targeted, the whole process quality control of medical records was realized, and a multi - faceted quality control system was constructed, which kept the rate of first grade medi- cal records in a high level.

关 键 词：全方位 病历 质控 体系 

分 类 号：R471[医药卫生—护理学]