产科病历质量控制体系研究规划

目的建立广东省产科病历质量控制体系，为产科病历系列质控提供参照标准。方法通过调查省内医院产科质量缺陷、产科医疗纠纷情况，分析存在的质量问题，设置各级医院产科病历质控重点，建立产科病历书写规范及评价标准，评价产科常见并发症临床路径的合理性。结果将产科质控标准与临床路径、病例分型有机结合，达到对产科常见病的平均住院日、平均医疗费、药占比等进行有效控制的目的。结论该质控体系已在广东省妇幼保健院试用，效果良好。

Study on the Quality Control System of Obstetrical Medical Records

Objective To establish the quality control system of obstetrical medical records in Guangdong province; give a reference criteria of obstetrical quality control in general hospital and maternal and child health care system. Method By investigating the defects of obstetrical quality, condition of obstetrical medical dispute of hospitals in Guangdong province ; analyzed the existing problems, made the main point of quality control of obstetrical records in all levels hospital, established the writing and evaluation standard obstetrical records, and evaluated the rationality of common obstetrical clinical path. Result The organic combination of clinical pathway, case classification and quality control standard of obstetrics had achieved the goal to control effectively the average hospitalization days, medical expense and drug proportion of obstetric diseases. Conclusion The quality control system had good effect after being carried on in the Women and Children＇s Hospital of Guangdong Province.