| 规范书写 加强质控 努力提高病历质量 |
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| 引用本文： | 季国忠.规范书写 加强质控 努力提高病历质量[J].江苏卫生事业管理,2010,21(2):1-3. |
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| 作者姓名： | 季国忠 |
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| 作者单位： | 南京医科大学第二附属医院,南京市,210011 |
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| 摘 要： | 医院质量管理是永恒的主题，病历质量是医院医疗质量的重要组成部分。认真规范的书写，严格细致的质量控制是提高病历质量的关键。文章对病历的作用、质量的现状以及提高病历质量的措施等作一探讨，指出规范书写病疗文件是医师的基本技能；健全和完善病历的管理组织和质控网络，对病历实行全程质量控制；加强“缺项质控”、推行“病种质控”和“路径质控”；重视电子病历的管理和质量控制：以严格的要求和科学的管理，使病历质量持续稳步提高。
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| 关 键 词： | 病历作用 质量控制 措施 |
Improvling the Quality of Medical Records with standard writing and Tlotal Quality Control |
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| Ji Guozhong,The Second Affiliated Hospital to Nanjing Medical University,Nanjing City,Jiangsu Province P.R.China.Improvling the Quality of Medical Records with standard writing and Tlotal Quality Control[J].Jiangsu Health Care Management,2010,21(2):1-3. |
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| Authors: | Ji Guozhong The Second Affiliated Hospital to Nanjing Medical University Nanjing City Jiangsu Province PRChina |
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| Institution: | Ji Guozhong,The Second Affiliated Hospital to Nanjing Medical University,Nanjing City,Jiangsu Province 210011 P.R.China |
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| Abstract: | Hospital quality management is an eternal subject for hospital administrators,and the quality of medical records is an important component part of good medical care performance.Careful and standardized writing with total quality control is the key to improve the quality of the case records.This paper discusses the functions of medical records,existing problems and measures to improve the quality of medical records.The paper points out that writing medical documents normatively is the basic skill of clinical... |
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| Keywords: | the role of medical records total quality control measures |
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