试论三种病历质量  

Discussion on Quality of Three Medical Records

作　　者：王继伟 王友明 丁俊涛 WANG Ji-wei WANG You-ming DING Jun-tao(The 478 Hospital of PLA, Kunming 650200, Chin)

机构地区：[1]解放军第四七八医院,云南昆明650200

出　　处：《医学与哲学（B）》2017年第7期91-93,共3页Medicine & Philosophy(B)

摘　　要：为了合理评价病历质量和改进病历质量检查工作,有必要把"病历质量"概念分解为"病历内涵质量"、"病历书写质量"和"病历管理质量"三个子概念,探讨了这三种病历质量的主要内容、规范标准和责任主体。评价病历内涵质量的关键要素是病历中所记载的诊疗措施是否正确合理以及相关医疗规章制度的落实情况。提高病历内涵质量需要责任主体本身的医疗行为做得好;需要改进"中央版"病历质量评价表,增加内涵质量评价内容;需要净化行医环境。In order to evaluate the quality of medical records better, it is necessary that the concept of medical quality is divided into three sub concepts： connotation quality of medical records, writing quality of medical records and management quality of medical records, discussesing the main contents, standard and responsibility subject of three medical record qualities.The key factor of evaluating the connotation quality of medical records is correctness and rationality related medical measures.From a single medical record, the connotation quality of medical record is almost synonym of the medical quality.In order to improve the connotation quality of medical records, the subjects of liability should do what should be done well and medical environment should be purified （eliminate hidden rules）.It is suggested to increase content of connotation quality in the central version quality evaluation list of medical records.

关 键 词：病历质量 病历内涵质量 病历书写质量 病历管理质量 

分 类 号：R197.323.1[医药卫生—卫生事业管理]