| 基于医院评审的病历质量缺陷分析与对策建议 |
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| 引用本文： | 钟旋,卢建军,陈婉东,李恒爱,刘全樑,刘秋生.基于医院评审的病历质量缺陷分析与对策建议[J].中国卫生质量管理,2014(5):45-47. |
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| 作者姓名： | 钟旋 卢建军 陈婉东 李恒爱 刘全樑 刘秋生 |
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| 作者单位： | 中山大学附属第一医院,广东广州510080 |
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| 摘 要： | 依据病历质量评分标准,对2035份缺陷病历进行分析.病历质量缺陷发生率为13.78％.质量意识淡薄,书写不及时,复制及漏缺项严重等是病历质量缺陷的主要原因.提出端正态度,提高医师自觉意识;分类培训,强化病历内涵质量要求;加强监管,健全分层管理联动机制;定期评比,奖优罚劣等对策建议.
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| 关 键 词： | 医院评审 病历 质量缺陷 |
Analysis and Countermeasures for the Quality Defects of Medical Records Based on Hospital Evaluation |
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| Institution: | ZHONG Xuan, LU Jianjun, CHEN Wandong, et al. (First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510080, China) |
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| Abstract: | According to the medical record quality criteria,2 035 medical records with defects were analyzed.The quality defect rate of medical records was 13.78％.The low quality consciousness,not timely writing,replication and lack of serious leakage were major causes of medical record quality defects.The paper pointed out that measures need to be carried out including attitude correction,consciousness improvement; classified training,strengthening the connotation of the medical record quality requirements ; strengthening supervision and improvement of the layered management linkage mechanism ; regular appraisal with bonus and forfeit. |
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| Keywords: | Hospital Evaluation Medical Records Quality Defects |
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