中国卫生产业
中國衛生產業
중국위생산업
China Health Industry
2015年
16期
96-97
,共2页
归档病历%缺陷%持续改进%质量控制%病历质量
歸檔病歷%缺陷%持續改進%質量控製%病歷質量
귀당병력%결함%지속개진%질량공제%병력질량
Archiving medical records%Defects%Continuous improvement%Quality Control%Quality of medical records
目的：通过对归档病历质控，查找、分析病历质量问题，制定病历质量持续改进措施，进一步提高病历书写质量，保障医疗安全。方法随机抽查该院2013年1月-2014年12月期间1500份归档病历，对其质量缺陷进行回顾性总结与分析，提出改进措施。结果通过加大病历质控与缺陷点评，病历书写质量明显提高，医疗质量有所改善，减少了医疗纠纷。结论加强病历质量考核工作，强化临床医师质量与安全意识，有针对性进行医务人员培训，可进一步防范医疗纠纷，提高医疗服务水平。
目的：通過對歸檔病歷質控，查找、分析病歷質量問題，製定病歷質量持續改進措施，進一步提高病歷書寫質量，保障醫療安全。方法隨機抽查該院2013年1月-2014年12月期間1500份歸檔病歷，對其質量缺陷進行迴顧性總結與分析，提齣改進措施。結果通過加大病歷質控與缺陷點評，病歷書寫質量明顯提高，醫療質量有所改善，減少瞭醫療糾紛。結論加彊病歷質量攷覈工作，彊化臨床醫師質量與安全意識，有針對性進行醫務人員培訓，可進一步防範醫療糾紛，提高醫療服務水平。
목적：통과대귀당병력질공，사조、분석병력질량문제，제정병력질량지속개진조시，진일보제고병역서사질량，보장의료안전。방법수궤추사해원2013년1월-2014년12월기간1500빈귀당병력，대기질량결함진행회고성총결여분석，제출개진조시。결과통과가대병력질공여결함점평，병역서사질량명현제고，의료질량유소개선，감소료의료규분。결론가강병력질량고핵공작，강화림상의사질량여안전의식，유침대성진행의무인원배훈，가진일보방범의료규분，제고의료복무수평。
Objective Through of filing for quality control of medical records,search,analysis of the problems existing in the quality of medical records,the establishment of the medical record quality continuous improvement measures,to further im-prove the quality of medical records,medical security. Methods 1500 records were randomly selected from January 2013 to December 2014 in our hospital.The quality defects were analyzed retrospectively, and the quality improvement measures were put forward. Results By increasing the quality of medical records and defects,the quality of medical records was im-proved obviously,the medical quality was improved and the medical disputes were reduced. Conclusion To strengthen medi-cal record quality assessment work, strengthen the clinical quality and safety awareness, targeted for the training of medical personnel, can further prevent medical disputes and improve the level of medical service.
