关于病案质量控制几个问题的思考

从目前病案质量控制的方法、过程和效果来看，出现了一种背离医疗质量的倾向。存在质控方法不当，表面化、形式化、弄虚作假，职责不清，奖罚不力，行政误导等问题。本文从完整病案质控机制，提高病案质控效能的目的出发，在提出上述问题的同时，分析了问题生产的原因，并提出：变终末质控为事前、事中质控，抓好全程、全员质量教育，实行责、权、利明晰的病案质控负责制，改变修改方式，坚持正确的卫生行政导向，认真落实各项病案质

Quality of Management of Case Book

Case book, from first to last page, in content, form, and style, should: possess strict serious, conscientious, scientific nature rather than superficial, mere formalities; reflect about natural history of disease and about how medical and surgical intervention can alter it beneficially or with possible side effects; facilitate to analyse different mechanisms of action, different profiles of interaction, relative advantages in procedures and therapies; record the clinial protocol, including details of operative techniques and treatments used; include detailed accounts if new procedures or modification of existing procedures have been employed, to make comparisons with those already conventionally used.