建立产科病历质量控制体系的思考

目的建立广东省产科病历质量控制体系，为省内妇幼保健系统和综合医院产科提供质量考评标准。方法通过与省内主要大型医院合作，完成产科病历书写规范、产科运行病历及终末病历评分标准、产科病种病例分型及平均医疗费和药品费比例控制等标准和规范的制定，使其成为广东省产科质量评价标准。结果制订了包括产科病历书写规范、产科运行病历及终末病历评分标准等质量评价体系。结论本体系可用于各级医院产科质量评价。

Study on the Quality Control System of Obstetrical Medical Records

Objective To establish the quality control system of obstetrical medical records in Guangdong province; and to provide evaluation standard of obstetrical quality in general hospital and maternal and child health care system. Method Through the cooperation with main large hospitals, standards were established which included the writing standard of obstetrical medical records, the scoring standard of obstetrical running records and final medical records, classification of obstetrical case types; controlled the average medical expense and the ratio of medicine cost. The standards were became the obstetrical quality evaluation standard in Guangdong province. Result The quality evaluation system of obstetrical medical records was made, including the writing standard of obstetrical medical records, the scoring standard of obstetrical running records and final medical records. Conclusion The quality evaluation system of obstetrical medical records can be used in all levels hospital in Guangdong province.