CAJ | 학술논문

我院现行住院病案质量控制体系尚未完全实现电子化，病案质量管理水平待进一步完善。为能从根本上加强病案质量控制，减少临床病案缺陷，消除医疗隐患，本研究拟通过分析病案书写缺陷，合理评价病案质量，建立并完善眼科住院病案四级质量控制体系，通过戴明环(PDCA)循环管理不断提高病案质量。
아원현행주원병안질량공제체계상미완전실현전자화，병안질량관리수평대진일보완선。위능종근본상가강병안질량공제，감소림상병안결함，소제의료은환，본연구의통과분석병안서사결함，합리평개병안질량，건립병완선안과주원병안사급질량공제체계，통과대명배(PDCA)순배관리불단제고병안질량。
The cur ent quality control system of medical record does not ful y go electronic, that perfecting the management of medical records control system is necessary in our hospital. To radical y intensify medical record quality control, reduce the defects of clinical medical record and eliminate the potential medical risk, this research built up four levels quality control system by careful y analyzing the writing defects of medical record and reasonably evaluating medical record quality in ophthalmology hospital. Throughout the process, the quality of medical record was improved by using the plan-do-check action (PDCA) cycle management.