病案质量整体管理的做法

Steps of holistic quality control of medical records

病案质量是衡量临床工作质量的重要标志。目前，因重效益轻质量、重科研轻临床现象突出，致病案质量有所下降。因此，应加强病案质量整体管理，建立医院、科室、个人三级病案质量控制体系；以病案内涵质量为核心内容，制定完善科学的病案质量评价标准；加强岗前培训，抓人员素质的提高；强化病案过程质量管理和终末质量管理，重视病案质量信息反馈作用。

Medical records are an important indicator of the quality of clinical work. At present, the dominance of financial considerations over medical quality and scientific research over clinical work cause the quality of medical records to drop. Therefore, holistic quality control of medical records should be strengthened to three level (hospital, department and individual) system, an evaluation standard of the quality fixed with the intensive content of the records as the nucleus, the prejob training intensified, the upgrading of personnel quality enforced, the intermediate and terminal quality control tightened, and the information feedback role of medical records stressed.