摘要
目的分析病案书写中存在的主要问题及原因,制定对策。方法参照病案书写规范制定相应标准,对出院病案和病案质量检查情况进行汇总。结果现存病案书写的及时性、完整性、真实性及知情同意类文件填写的规范性以及相关核心制度落实的确切性仍有待提高。结论病案质量是医疗质量的重要内容,为保障医疗质量的可持续改进,需要实施有效的质量监控。
Objective To analyze the main problems in the medical record writing and propose an appropriate strategy. Methods Written in reference to medical record standards to formulate appropriate standards, the quality of hospital medical records were summarized. Results The writing timeliness, integrity, authenticity, and informed consent, filled out the normative class files and the implementation of the core system were remained to be further improved. Conclusions Record quality is an important part of medical quality. To ensure the sustainable improvement of medical quality, the effective quality control should be implemented.
出处
《解放军医院管理杂志》
2010年第7期666-667,共2页
Hospital Administration Journal of Chinese People's Liberation Army
关键词
病案质量
问题分析
对策
medical record quality
problem analysis
countermeasure
作者简介
[作者简介]张婷，女，护师；电话：025—80861382
[通讯作者]申萍，电话：025-80861282
