以问题为导向病案质量监控对规范医疗行为的影响  

Influence of Problem-Oriented Medical Record Quality Control on Standardizing Medical Behavior

作　　者：李丽华[1] 焦震宇[1] Li Lihua;Jiao Zhenyu(Beijing Chaoyang Hospital,Capital Metiical University,Beijing 100020,China;不详)

机构地区：[1]首都医科大学附属北京朝阳医院,北京市100020

出　　处：《中国病案》2020年第8期26-28,共3页Chinese Medical Record

摘　　要：以问题为导向的病案质量监控可以有针对性地提出问题,依据相应的指南或医疗规范制定专项的检查标准,快速便捷的找到同类问题的源头,并深层次多角度地挖掘造成该问题的原因,进而制定有效策略,以杜绝该类错误的发生。同时规范的医疗行为也是提高病历书写质量的有力支撑,是实现医院管理标准化的基础。通过对同类型疾病病案的检查,可以深度挖掘,寻找问题的源头,治理源头问题,从根本上杜绝相似缺陷的再次发生。也就是带着问题看病案,透过病案看医疗过程和医院、科室管理的规范性,带动医疗行为的标准化。另外,多种病案质控模式同时运行可以使病案质控更加全面。The problem-oriented quality control of medical records can raise questions pertinently, formulate special inspection standards according to corresponding guidelines or medical standards, and quickly and easily find the source of similar problems. and deep-seated multi-angle excavation of the causes of the problem, and then formulate effective strategies to put an end to the occurrence of this kind of errors. At the same time, standardized medical behavior is also a strong support to improve the quality of medical record writing, and is the basis for the standardization of hospital management. Through the examination of the medical records of the same type of diseases, we can dig deeply, find the source of the problem, control the source of the problem, and fundamentally put an end to the recurrence of similar defects. That is, to see the medical records with problems, to see the standardization of the medical process and the management of hospitals and departments through the medical records, so as to promote the standardization of medical behavior. In addition, the simultaneous operation of a variety of medical record quality control modes can make medical record quality control more comprehensive.

关 键 词：以问题为导向 病案质量监控 医疗质量 标准化 

分 类 号：R197.323[医药卫生—卫生事业管理]