基于院科两级质控管理体系的终末病历质量督查模式探讨  

Quality Supervision Mode of Final Medical Records Based on Hospital and Department Quality Control Management System

作　　者：毛淋淇 杨静[1] 徐婉瑛[2] MAO Linqi;YANG Jing;XU Wanying(Ruijin Hospital Affiliated to School of Medicine of Shanghai Jiaotong University, Shanghai,200025, China;不详)

机构地区：[1]上海交通大学医学院附属瑞金医院,上海200025 [2]上海交通大学医学院附属瑞金医院医务一处,上海200025

出　　处：《中国卫生质量管理》2021年第9期32-34,41,共4页Chinese Health Quality Management

基　　金：上海申康医院发展中心管理研究项目(2020SKMR-26)。

摘　　要：病历质量是医院医疗质量和管理水平的体现。为解决传统病历质控中人员匮乏、工作负担重、临床参与度不高等问题,构建了基于院科两级质控管理体系的终末病历质量督查模式,同时利用信息化手段实现了病历质控工作的闭环管理。实践结果表明,这种模式提高了病历质控工作的精细化管理水平。The quality of medical records is the embodiment of the medical quality and management level of a hospital.In order to solve the problems of lack of personnel,heavy workload and low clinical participation in the traditional quality control of medical records,the quality supervision mode of the final medical records based on the hospital and department quality control management system was constructed,and the closed loop management of the quality control of medical records was realized by using information means.The practice results showed that this mode improved the fine management level of medical record quality control.

关 键 词：终末病历 病历质量 质量督查 质控管理体系 闭环管理 全流程 

分 类 号：R197.323[医药卫生—卫生事业管理]