医院病案首页质量监控存在的问题及对策

医院的病案首页记录了包括患者从入院到出院的诊断、治疗全过程,病案首页的质量高低反映了医院管理情况以及医院综合情况,是医院管理的重点。2012年1月我国卫生计划委员会组织会议并专门制定住院病案首页的填写及修改方案全国范围内开始实施。但临床实行过程中,由于多种原因和医院实际医疗条件限制,医院病案首页的质量管理仍存在较多问题。本文通过研究总结文献和期刊等,结合临床医院病案首页监控,将存在问题进行指出,并分析问题产生的主要原因,提出有效的对策,加强病案及病案首页的质控管理,最大程度的为患者提供良好的医护服务。

Problems and Countermeasures in the Quality Control of Home Page of Hospital Medical Record

The home page of hospital medical record records the whole process of diagnosis and treatment including the patient’s admission from hospital to discharge. The quality of the medical record home page reflects the hospital management and hospital comprehensive situation, which is the focus of hospital management. In January 2012, China Health Planning Committee organized a meeting and specially formulated the filling and modification plan for the inpatient medical record homepage to be implemented nationwide. However, during the clinical implementation process, due to various reasons and the actual medical conditions of the hospital, the quality management of the hospital medical record homepage still has many problems. This paper summarized the literature and journals, and combined with the monitoring of the home page of clinical hospitals to point out the existing problems,analyzed the main causes of the problems, proposed effective countermeasures, and strengthened the quality control of the medical records and medical records on the front page, which can provide good medical care for patients to the maximum extent.