医院间病案互评新模式探索

病案质量是医疗质量管理的重点,提高病案质量,加强病案质量管理至关重要。我院与省内其他三甲医院开展病案互评活动以来,医院间取长补短,取得了较好的质控效果,在病案首页信息完整、出院记录出院医嘱详细、病程拷贝、上级医师查房内涵、不正确修改病案等方面均有较大改善,病案质量得到全面提升。同时,病案互评活动还提高了互评医院质控人员的病案质控水平,充分调动了临床医师自我病案质控,书写高质量、高标准病案的积极性,主动性。病案互评为病案质控提供了新的模式,是医院内病案质控的有力补充。通过病案互评程序的不断完善,使病案互评模式得到持续改进。

New Mode Exploration of Medical Records Mutual Evaluation Among Hospitals

The quality of medical records is the key point of the quality management of medical treatment,so it is of great importance to improve the quality of medical records and strengthen the quality management of medical records.Since the medical records mutual evaluation our hospital carried out with other tertiary class A hospitals in our province,we had learned from hospitals each other and got well quality control effect,the quality of medical records was improved comprehensively in many aspects,such as information integrity of home pages of medical records,discharged records details,copy of diseases course,ward round connotation of superior doctors and incorrect modification of medical records.At the same time,the mutual evaluation activities also improved the quality control level of the quality control staff,fully arouse the enthusiasm and initiative of clinicians make quality control themselves to realize high writing quality and standard medical records.Medical records mutual evaluation provided new mode of quality control of medical records and was a good compensation of medical records quality control within hospital.The mutual evaluation mode could be improved continuously through the constant improvement of medical records mutual evaluation progress.