病案首页的多方位质控

Multi-faceted quality control of the home page of medical record

目的:探寻病案首页质量控制的方法及措施,使病案首页信息更安全可靠、可用性好。方法对改进首页质控方法后的病案首页质量情况进行分析总结。结果首页存在的错填、漏填、选错、缺签名等问题均较前减少。结论只有临床医师、病案管理人员及医院管理部门共同努力,对病案首页采取多方位质量监控,才能有效提高病案首页的质量。

Objective To explore the methods of quality control on the home page of medical records,so as to make it more availability.Methods Analysis and summary the quality of the home page of the medical records recently.Results The problems such as missing signatures decrease now.Conclusion Clinicians,medical records managers and hospital administration should work together to improve the quality of the home page of the medical record,and multi-faceted measures must be taken for it.