规范病历书写 确保病案内涵质量

根据前卫生部《病历书写基本规范》和《医疗机构病历管理规定》的要求,病案内涵质量的关键是真实性、基础是准确性、保障是及时性。提高病案内涵质量的方法从健全科室监督、完善考评制度、加强环节质控、定期法律培训入手,提高病案内涵质量的根本在于临床医师,最大限度的挖掘各级医师的管理职能。病案内涵质量的改善需要终末质量监控人员内外联合,最终实现医务人员法律与服务意识的整体提升。

Make the Medical Record Writing Specification to Ensure the Quality of Medical Record Connotation

According to the request of the ministry of health the medical record writing basic specification and regulations on the medical record management of medical institutions, the key of medical record quality connotation is authenticity, the basis is accuracy, the security is timeliness. Methods to improve the quality of medical record content are the supervision department improvement, perfecting the evaluation system, strengthen link quality control, legal training on a regular basis. Clinician is fundamental to improve the quality of medical record connotation, maximum mining physician at all levels of management function. The improvement of the connotation of the medical record quality need inside and outside the joint of final quality control personnel, finally realizes the improvement of overall ascension of law and sense of service.