病历书写新规范的解读与实践

目的通过认真学习落实卫生部《病历书写基本规范》,强化医务人员安全意识,提高医疗质量,保障医疗安全。方法根据新《规范》精神,结合医院实际,采取一系列强化医疗质控及医疗安全教育等措施,不断持续改进病案质量,提高医疗质量。结果提高全员医疗质量意识和医疗安全意识,使医疗纠纷发生率、医疗事故投诉率与同期相比有明显下降。结论落实新规范,加强病案质量管理,有效防范医疗纠纷,保障医疗安全。

Explanation and Practice of New Writing Standard of Medical Record

Objective Through carefully studying and carrying out Basic Standard of Medical Record Writing of ministry of health strengthen safety consciousness of medical staffs,improving medical quality and ensuring medical safety.Methods According to new Basic Standard of Medical Record,combing actual situation of hospital,a series of countermeasures of strengthening medical quality control and medical safety education are adopted.Quality of medical record and medical quality are improved continually.Results Conscio...