病历内涵质量管理体系的建立与实践  

Establishment and Practice the Connotative Quality Management System of Medical Records

作　　者：王怡[1] 段文利[1] 庞成[1] 赵晓娟[1] 陈政[1] 

机构地区：[1]北京协和医院,北京100730

出　　处：《中国卫生质量管理》2017年第5期32-34,共3页Chinese Health Quality Management

摘　　要：为进一步提升病历内涵质量,传承北京协和医院高标准、严要求的病历传统文化,特聘资深临床专家组成病历内涵质控团队,设定病历内涵质控评价标准,并设立不良拷贝单项否决。构建了以病历内涵质控为核心、三级质控为架构、院科互动的全程病历质量管理体系。病历内涵质量优良率从64.95%提高至88.98%,使病历内涵质控成为提高医疗质量的重要抓手。To further enhance the connotative quality of medical records and inherit the traditional culture in Pec king Union Medical College Hospital on medical records writing with high standards and strict requirement, senior clinical experts were invited to participate in the expert team for medical record quality control. The evaluation criteria of the connotative quality of medical records were innovatively set, and the single veto for the plagiarism behavior of writing medical record was also involved. Using the connotative quality control of medical records as the core, a three levels framework of quality control had built with the full range of medical records quality management system between faculties and hospital. The excellent rate of connotative quality of medical records was improved from 64.95 % in the early stage of quality control by experts to 88.98%, which made the connotative quality control of medical records become a significant measure for medical quality.

关 键 词：病历 内涵质量 管理 体系 实践 

分 类 号：R197.323[医药卫生—卫生事业管理]