四个层面两种手段全面深入提高病历书写质量

病历书写质量是医疗质量和医疗安全的根本保障,是医院临床医疗工作稳健运行和快速发展的基石,然而现实情况是临床医师往往放松对病历书写质量的要求,忽略对病历的及时修改完善。本文探讨造成此种现象的思想根源,并提出相应的管理对策。结论知识、意识、意志、意愿是影响临床医师病历书写质量的四个思想要素,通过培训和考核使医师具备完善的病历书写规范知识,通过通告和检查,强化医师的病历书写意识,通过奖励和惩罚坚定医师写好病历的意志,通过案例教育培养医师主动写好病历的意愿,通过客观条件的改善克服医师写好病历面临的客观困难,如此全方位多层次地对临床医师病历书写工作进行管控,能较好地提高病历书写质量。

Improve Medical Record Writing Quality with Two Methods from Four Aspects

Medical record writing quality is the guarantee of medical quality and medical safety and the cornerstone to steady and fast development of hospital clinical medical work.However,the clinicians tend to pay little attention to the medical record writing quality and ignore the timely modification to medical record.This paper discusses the root causes of this phenomenon and puts forward corresponding management countermeasures.Conclusion Knowledge,awareness,volition and will are four influencing factors of clinicians＇ attitudes toward medical record writing.Medical record writing quality can be effectively improved by following measures： increasing clinicians＇ knowledge of medical record writing specifications through training and examination,strengthening clinicians＇ awareness of medical record writing through notification and inspection,affirming clinicians＇ volition through rewarding and punishing,developing clinicians＇ will to write high quality medical record and decreasing objective difficulty in medical record writing though improving objective conditions.