门诊病历质量调查分析及持续改进  

Survey Analysis and Continuous Improvement of Medical Record Quality in Outpatient Service

作　　者：黄翔[1] 

机构地区：[1]南通大学附属医院门诊部,江苏南通226001

出　　处：《中国卫生产业》2016年第20期173-175,共3页China Health Industry

摘　　要：目的通过门诊病历质量检查,提高门诊病历质量。方法随机抽取2015年门诊病历,按照门诊病历质量评分标准,进行检查分析。结果门诊病历合格率97%,不合格门诊病历最常见缺陷为现病史书写不全。结论门诊病历质量检查是医院医疗质量管理的重要组成部分,医院要通过门诊病历质量检查,找出门诊病历的质量缺陷,分析原因,制定改进措施,提高门诊病历质量。Objective To improve the medical record quality in outpatient service by examination of medical record quality in outpatient service. Methods The medical records in 2015 were randomly extracted, and the examination and analysis were conducted according to the evaluation standards of medical record quality in outpatient service. Results The qualified rate of medical records in outpatient service was 97%, and the most common defect in the unqualified medical records in outpatient service was insufficient medical history writing. Conclusion The examination of medical record quality in outpatient service is an important component in the hospital medical quality management, and hospitals should find out quality defects of medical record quality in outpatient service, analyze causes, make improvement measures and improve the medical record quality in outpatient service by examination of medical record quality in outpatient service.

关 键 词：门诊病历 质量 持续改进 

分 类 号：R197.3[医药卫生—卫生事业管理]