我院病历全面质量管理的构想与实践

Conception and practice of total quality management of medical records in our hospital

从全面质量管理理念出发，对实施病历全面质量管理进行了初步构想，进一步明确了病历质量控制的功能定位及拓展，贯彻全程、全员、全面质控的理念，重视病历质量控制中的反馈和交流环节，强化质量文化的建设和传承。同时在病历质量控制实践中，从组织体系的完善、评价指标体系的调整、质控关键点的确定、环节质控与终末质控的结合、质控培训体系的建设等方面，加强了病历质量控制的综合管理力度。

Based on the idea of total quality management, the preliminary conception on the implementation of total quality management of medical records is advanced, which further specifies the function and its expansion of quality control of medical records, implements the idea of whole course, whole staff, and comprehensive quality control, attaches importance to the feedback and communication in quality control, and strengthens the construction and preservation of quality culture. Meanwhile, quality control of medical records is strengthened by the practice of comprehensive management, including perfection of organization system, adjustment of evaluation system, definition of key points of quality control, combination of process quality control and terminal quality control, establishment of training system of quality control, and so on.