住院病案精细化质量管理体系的建立与应用

目的通过建立住院病案精细化质量管理体系,加强住院病案质量控制,减少临床病案缺陷以消除医疗隐患。方法针对住院病案存在的15类问题,建立住院病案精细化管理基本模式:制定一套量化、细化的住院病案精细化评价标准,建立三级病案质控负责制,开展持续的住院病案精细化管理培训,通过PDCA循环管理不断提高病案及医疗质量。结果基本杜绝了住院病案的严重缺陷,病案中的重大差欠数明显减少,医护人员对病案质量的重视度明显提高。结论建立和应用住院病案精细化质量管理体系能有效减少病案缺陷,提高医疗质量。

Construction and Application of Refined Quality Management System of Medical Records of Hospitalization

Objective：To reduce the number of defects in clinical medical records and eliminate health hazards by building refined quality management system of medical records of hospitalization and enhancing control over the quality of medical records of hospitalization. Method：The basic model of refined quality management system of medical records of hospitalization is established to solve the 15 problems in medical records of hospitalization with a set of quantitative and re- fined evaluation standards of medical records of hospitalization, quality control responsibility system of medical records of Class HI and starting sustaining training for the refined management of medical records of hospitalization. And the improve- ment in the quality of medical records and medical treatment PDCA cycle management is achieved. Result： Serious defects in medical records of hospitalization have been basically eradicated;the number of major differences and lacks in medical records decreased distinctly;and medical workers paid more attention to the quality of medical records. Conclusion：The construction and application of refined quality management system of medical records of hospitalization can effectively re- duce the defects of medical records and improve medical quality.