CAJ | 학술논문

目的：探讨通过对三级综合医院病历书写时限性管理来提高病历质量管理水平。方法制定检查标准：检查位点的要求；实施奖罚结合措施。结果笔者通过对病历书写时限性制度化、病历书写规范化三年的严格管理，并与前三年检查结果进行对比，运行病历书写合格率从91.3%上升为96.53%。2010~2013年6月份运行病历书写时限性合格率从88.03%上升为96.53%，效果明显提高。结论通过从病历书写时限性动态化、病历书写规范化的管理，实施奖罚结合措施是提高病历质量管理水平的关键，值得全国各家医院借鉴。
목적：탐토통과대삼급종합의원병역서사시한성관리래제고병력질량관리수평。방법제정검사표준：검사위점적요구；실시장벌결합조시。결과필자통과대병역서사시한성제도화、병역서사규범화삼년적엄격관리，병여전삼년검사결과진행대비，운행병역서사합격솔종91.3%상승위96.53%。2010~2013년6월빈운행병역서사시한성합격솔종88.03%상승위96.53%，효과명현제고。결론통과종병역서사시한성동태화、병역서사규범화적관리，실시장벌결합조시시제고병력질량관리수평적관건，치득전국각가의원차감。
Objective To improve the quality management level of medical record through the time-limited dynamic management in medical record writing of third-class comprehensive hospital. Methods To formulate examination standards. To check the requirement of interaction site. To actualize the measures of rewards and punishments. Results The qualified rate of medical record writing was ascendant compared with the examination results 3 years ago from 91.3%to 96.53%, through 3 years' strict management of time-limited institutionalization and standardization of medical record writing. The time-limited qualified rate of medical record writing was ascendant from 88.03% to 96.53% between June 2010 and June 2013, while the effect of which had been improved obviously. Conclusion To actualize the measures of rewards and punishments through the management of time-limited dynamic and standardization of medical record writing is the key to improve the quality management level of medical record, is worthy of reference by every hospital for the whole country.