病历质量管理中存在的问题及对策

The Problems in the Quality of Medical Record Management and the Countermeasures

病历质量反映一个医院的整体水平,但目前国内在病历质量管理中仍存在着种种的问题。病历书写字迹潦草、记录不及时、病案首页填写不合规定、病史采集不详细、体格检查、阴性资料记录不全面、阳性资料分析不够、授权委托书和知情同意书落实不好、进修实习生书写病历不符合要求、代签字现象。病案管理方式落后、管理人员整体素质低、观念落后。建议和对策:培养专业人才;主管部门和医疗机构领导要重视;要提高医务人员的法律维权意识、培养医务人员的敬业负责精神;建立切实可行的病历质量考核制度;合理简化病历书写内容。

The medical record quality reflects the overall level of a hospital, but at present there are various kinds of problems in the medical record quality management. One of them is the documentation of the medical record, for example, illegible handwriting, premature writing of the medical records, nonstandard the home page, incomplete and carefree medical history collection, non-impersonal physical examination, incomplete negative materials, insufficient analysis in the positive materials, nonstandard documents of trust deed and consent, non-qualified medical records, replaced signature. Another is the problems of management, such as, the behindhand way of management, the staff members＇ low quality, the lagging management idea. In view of the above problems, the author puts forward the following proposals： the first is to train the professionals; the second is regard from the upper department in charge of the medical record; the third is the recognition of the leaders; the four is to raise sense of law of medical record personnel; the fifth is to train cultivate the personnel＇s sense of responsibility; the sixth is to establish the practical and feasible medical record quality system; the seventh is to simplify the content of the medical record.