CAJ | 학술논문

在病案形成过程中对存在的问题进行分析，有针对性地提出解决办法，落实相关措施，提高病案质量，确保病案内容真实可靠，是病案管理工作的重中之重。通过严格落实《病案管理规定》、狠抓质量缺陷源头，落实环节与终末相结合质控机制、开展病案质量网上展览和建立严格规范的病案修改审批制度及奖惩措施等，提高了病历书写过程中的医务人员病历书写水平和管理意识，使出院归档病案质量有了显著的提高。
재병안형성과정중대존재적문제진행분석，유침대성지제출해결판법，락실상관조시，제고병안질량，학보병안내용진실가고，시병안관리공작적중중지중。통과엄격락실《병안관리규정》、한조질량결함원두，락실배절여종말상결합질공궤제、개전병안질량망상전람화건립엄격규범적병안수개심비제도급장징조시등，제고료병역서사과정중적의무인원병역서사수평화관리의식，사출원귀당병안질량유료현저적제고。
Analyze existing problems, put forward some solutions, carry out the relevant measures, improve the quality of medical record, and ensure the medical record is reliable, is the key of the medical record management. We should strictly implement the medical record management stipulation, find the quality defect source, implement link and terminal quality control mechanism, carry out the medical record quality online exhibitions and establish a strict medical record amend approval system and rewards and punishments measures, improve the level of medical record writing of the medical staff and management consciousness, make the hospital archive medical record quality improve significantly.