某三级甲等医院提高病历质量的做法

目的通过改变管理思路和模式，提高医院病历书写质量。方法分别安排返聘专家对重点终末病历和中高级职称医师对普通终末病历逐份进行检查，查找病历中的质量缺陷，对存在问题有针对性地加强培训，同时建立相应的奖惩机制。结果病历终末质量有了明显提高，合格率保持在98％以上，医疗纠纷大大减少。结论加大对病历终末质量的检查力度，杜绝书写者的侥幸心理，增强各级质控人员的质控意识，为职能部门管理和培训提供重要依据，此举是提高病历质量的一种有效方法。

Experience on Improving Medical Record Quality of Certain Third -grade Class -A Hospitals

Objective To improve the quality of medical records through changing the management model and idea. Methods Reemployment experts and doctors with intermediate and advanced titles check on the quality of key and general terminal medical records one by one separately. Once quality defects been found, we would carry out special training, and establish viable incentive mechanisms of praise and punishment. Results The terminal quality of medical records improved significantly. Qualified rate of terminal medical records remain above 98%. Medical dis- putes decreased greatly. Conclusion The hospital should reinforced the checking on the quality of terminal medical records to eliminate the writer＇s mind of taking chances, and enhance the staffs consciousness on quality control These measures would provide an important basis for the management and training of functional departments.