CAJ | 학술논문

目的通过探讨病案质控的措施,提高医院病案质量.方法回顾性分析病案质控管理中的实践体会,建立符合标准化、科学化、系统化的五级综合质控管理体系,通过加强运行病历监控考核、归档病案的终末质控,落实多层次的有效监控措施,并建立激励机制.结果杜绝了丙级病历,病案质量得到整体提高,同时内涵质量也得到同步提高.结论建立五级质控体系,落实多层次质控措施是有效提升住院病案质量的途径.
목적통과탐토병안질공적조시,제고의원병안질량.방법회고성분석병안질공관리중적실천체회,건립부합표준화、과학화、계통화적오급종합질공관리체계,통과가강운행병력감공고핵、귀당병안적종말질공,락실다층차적유효감공조시,병건립격려궤제.결과두절료병급병력,병안질량득도정체제고,동시내함질량야득도동보제고.결론건립오급질공체계,락실다층차질공조시시유효제승주원병안질량적도경.
Objective To improve the quality of medical records by investigating effective measures of quality control .Methods To establish a standardized ,scientific and systematic five levels quality control management system by retrospectively analyzing the prac -tice experience .Through ,strengthening the medical record operation monitoring assessment and examination of terminal medical records ,we can take multiple effective measures to achieve multi-level monitoring control and establish incentive mechanism at the same time .Result Eliminate the C-level medical records ,and improve the overall quality of medical records as well as the connotation quality .Conclusions With the establishment of five levels quality control management system and the carring out of multiple effective measures in quality control ,the quality of medical records was improved effectively .