1144份住院病案终末质量监控

Final Quality Control of 1144 Copies of Hospitalization Medical Records

目的探讨病案终末质控方法在病案质控中的重要作用。方法以病案书写规范为标准,对1144份病案进行检查、分析缺陷。结果缺陷病历共214份,共365个缺陷项次,总缺陷病历率18.7%,并根据大项、小项、专业缺陷发生情况,制定系列对策。结论病案终末质控的重要性并不是对病案的返修,而是查找病案缺陷的根本原因,持续改进病案质量。

Objective This paper discusses the important role of final quality methods in quality control of medical records.Methods As the standard of writing norms of medical records 1144 medical records are had examination and defects analysis.Results There are 214 defects medical records with 365 defect items,which defects rate is 18.7%.According to big items,small items and professional defects,it makes up a series of countermeasures.Conclusion The importance of final quality control of medical records is not to re-amend but to find out the basic reasons of medical records defects and to continually improve the medical records quality.