病案管理的内涵建设与质量监控

病案作为重要的医疗文书,是衡量临床医疗工作质量的重要标志之一,是处理医疗纠纷时实施"举证责任倒置"重要的法律依据.我院非常重视病案文书的管理和病历质量检查工作,从提高人员素质、健全质控体系、规范管理标准、提升管理手段和启发管理层的重视等五个方面进行了大胆的探索,取得了良好的效果,医院病案文书质量与管理水平有了显著提高.

Improving the Quality control of Medieal Record Management in Deeper connotation

The medical records, as the important documents in the hospitals, are the indicators to see whether the health care given is proper or not. And they are also the evidence while dealing with medical disputes, especially for the "Evidence Provided by Litigant" regulation issued recently. The administrators in our hospital pay special attention to five aspects in medical record management including the management documentation and quality control of medical records, the quality of the personnel, the controlling system, the standardization and the quality of management, and taking measures to explore in the five aspects.