| 病历质量监控及管理实践 |
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| 引用本文： | 邓明德,叶静,张椿,龙其生.病历质量监控及管理实践[J].解放军医院管理杂志,2010,17(4):315-317. |
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| 作者姓名： | 邓明德 叶静 张椿 龙其生 |
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| 作者单位： | 第三军医大学新桥医院质控科,重庆,400037 |
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| 摘 要： | 目的通过对病历质量监控及管理的实践,提高病历质量。方法分别对基础质量、环节质量、终末质量的监控和管理进行分析,阐述了在监控环节中对医疗保险及使用抗菌药物进行监控的内容。结论落实基础质量、环节质量、终末质量是提高病历质量的根本保证,强化对病历监控力度及制定完善的管理措施是提高病历质量的重要手段。
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| 关 键 词： | 病历质量 电子病历 纸质病历 |
Monitoring and Management of Medical Record Quality |
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| DENG Ming-de,YE Jing,ZHANG Chun,LONG Qi-sheng.Monitoring and Management of Medical Record Quality[J].Hospital Administration Journal of Chinese People's Liberation Army,2010,17(4):315-317. |
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| Authors: | DENG Ming-de YE Jing ZHANG Chun LONG Qi-sheng |
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| Institution: | (Department of Quality Control,Xinqiao Hospital,Third Military Medical University,Chongqing 400037) |
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| Abstract: | Objective To improve the quality of medical records through the practice of monitoring and management of medical record quality.Methods The monitoring and management of the basis quality,process quality,and terminal quality were analyzed respectively.The medical insurance and the use of antimicrobial agents in the control areas were described particularly.Conclusion The implement of basic,process and terminal quality was the fundamental guarantee of improving medical record quality.It were the important means of improving the quality of medical records by strengthening the monitoring efforts and formulating perfect management measures. |
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| Keywords: | medical record quality electronic medical record paper medical record |
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