某院病历书写质量管理现状  

Status of Quality Management about Medical Record in a Hospital

作　　者：张延丽 赵建军[1] 周琳[1] 樊震林[1] ZHANG Yanli ZHAO Jianjun ZHOU Lin FAN Zhenlin(Department of Education and Administration, Eastern Hepatobiliary Hospital, Second Military Medical University, Shanghai 201805)

机构地区：[1]第二军医大学附属东方肝胆外科医院医教部,上海201805

出　　处：《解放军医院管理杂志》2017年第9期818-820,共3页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：随着医学科学的飞速发展和医疗法律法规的不断完善,病历档案的重要性日益凸显。文章以上海市某三甲医院的运行病历、终末病历为研究对象,分析病历质量管理的现状和问题,并结合医院管理实际,从科学管理的角度提出进一步提高病历书写管理质量的对策。With the rapid development of medical science,medical laws and regulations,medical record is becoming more and more important. In this paper,we took the medical record in a Grade A Class Three hospital in Shanghai as the study,object and analyzed the current situation and problems of quality management about medical record. Finally,this paper put forward some countermeasures to improve the quality of management.

关 键 词：病历书写 质量管理 现状 对策 

分 类 号：R197.32[医药卫生—卫生事业管理]