CAJ | 학술논문

通过病案质控暴露出病案书写质量的病案号错填、重复或空号、首页诊断填写不规范、项目错填或漏填、医嘱与知情同意书签署缺陷及病历归档不及时等问题；依据《病历书写基本规范》，结合电子病历书写的及时性、完整性、真实性及病历文书规范要求，强化法律意识，夯实医学基础，严抓环节质量，落实质量问责制，依法管理病案及重奖惩激励等措施，减少缺陷病案发生、规避医疗纠纷、确保医疗安全、以提高病案管理质量科学、规范、安全要求。
통과병안질공폭로출병안서사질량적병안호착전、중복혹공호、수혈진단전사불규범、항목착전혹루전、의촉여지정동의서첨서결함급병력귀당불급시등문제；의거《병역서사기본규범》，결합전자병역서사적급시성、완정성、진실성급병력문서규범요구，강화법률의식，항실의학기출，엄조배절질량，락실질량문책제，의법관리병안급중장징격려등조시，감소결함병안발생、규피의료규분、학보의료안전、이제고병안관리질량과학、규범、안전요구。
Exposed through medical record medical record medical record number wrong writing quality fil , repetitive or empty, home diagnostic fil are not standardized, fil the wrong item or Loutian, medical advice and consent form signed by not timely filing defects and medical problems;basis"medical records basic norms", combining electronic medical records timeliness, integrity, authenticity and medical instruments regulatory requirements, and strengthen legal awareness, reinforce basic medical, Strict quality aspects, the implementation of quality accountability, according to management medical record and re-reward and punishment and other measures to reduce the occur ence of defects in the medical record, to avoid medical disputes and ensure medical safety, in order to improve the quality of case management science, specifications, safety requirements.