| 质量监控促进病案质量持续提高的探讨 |
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| 引用本文： | 马钰香,洪雅萍,沈彩珠.质量监控促进病案质量持续提高的探讨[J].中国病案,2009,10(4):11-12. |
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| 作者姓名： | 马钰香 洪雅萍 沈彩珠 |
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| 作者单位： | 南京医科大学第一附属医院质量控制科,南京市,210029 |
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| 摘 要： | 目的促进医院病案质量持续提高后的质控探讨。方法对我院2008年1月～9月住院病案质量检查中发现的缺陷及原因进行分析。结果病案质量主要在及时性、完整性、规范性等方面仍存在缺陷，这与我院工作量大、重危患者多等现实原因有关，也有医师对病案质量重视不够、制度执行不严等主观原因。结论加强环节质控为导向，从质控体系、质控方法、制度建设、质量教育等多方面人手提高病案质量。
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| 关 键 词： | 病案 病案质量 质控 |
The Exploration of Quality Control Countermeasures of Improving Medical record Quality Continually At Present |
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| Ma Yuxiang,Hong Yaping,Shen.The Exploration of Quality Control Countermeasures of Improving Medical record Quality Continually At Present[J].Chinese Medical Record,2009,10(4):11-12. |
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| Authors: | Ma Yuxiang Hong Yaping Shen |
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| Institution: | (Quality Control Department of First Attached Hospital of Nanjing Medical University Nanjing 210029) |
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| Abstract: | Objectives To explore the countermeasures of improving medical record quality continually. Methods inspect quality of medical records from January to September 2008 in our hospital to find out defects and analyze the reasons. Results the defects of medical record quality appear in betimes, integrity normative and etc aspects. It related to heavy workload and plenty critical patients. The subjective reasons are doctors＇ less attention to medical record quality and less- strict - executive System. Conclusions put segment quality control implement as an orientation to improve medical record quality through quality control system, quality control methods, system construction and quality education. |
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| Keywords: | medical record medical record quality quality control |
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