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加强在院病人病历书写质量监控
引用本文:陈传本,陈少雄. 加强在院病人病历书写质量监控[J]. 中国病案, 2010, 11(5): 30-31
作者姓名:陈传本  陈少雄
作者单位:福建省肿瘤医院质控办,福州市,350014
摘    要:
提高病历的书写质量,必然要加强对病人住院期间病历书写的环节质量进行实时监控,把缺陷消灭在病历形成过程中,保证病历书写及时、客观、真实、全面,进而保障医院安全,防范医疗纠纷。

关 键 词:病历  质量控制  方法  体会

Practice and Experience on Strengthening Quality Control of Medical Records
Chen Chuanben,Chen Shaoxiong,Quality Control Office of Fujian Provincial Tumor Hospital,Fuzhou ,China. Practice and Experience on Strengthening Quality Control of Medical Records[J]. Chinese Medical Record, 2010, 11(5): 30-31
Authors:Chen Chuanben  Chen Shaoxiong  Quality Control Office of Fujian Provincial Tumor Hospital  Fuzhou   China
Affiliation:Chen Chuanben,Chen Shaoxiong,Quality Control Office of Fujian Provincial Tumor Hospital,Fuzhou 350014,China
Abstract:
To improve writing quality of medical records,it’s necessary to strengthen real-time monitoring on quality for the link of running medical records to make up for deficiencies in the process of medical records formation,which ensure that records write timely,objectively,truthfully and comprehensively,and thus to guarantee hospital safety and prevent medical disputes.
Keywords:Medical records  Quality control  Methods  Experience  
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