从医疗保险的需要谈病案质量控制的重点与对策

A Discussion on the Key Points and Countermeasures of Quality Control according to the Medical Insurance Requirements

目的探索医疗保险病案质量控制的重点与对策。方法通过对76份医疗保险缺陷病案的分析,提出5个方面的控制重点。结果医疗保险给病案质量赋予了新的内涵,对病案书写的及时性、准确性、全面性、完整性和合理性等方面提出了更高的要求。结论通过开展质量教育,进行病案书写培训,制订病案质量控制标准和完善质量监控体系,加强医保病案管理,促进了医保病案质量的提高。

Objective To explore the key points and the countermeasures of medical records quality control for the implementation of medical insurance. Methods Based on the analysis of 76 medical records with deficiencies, we put forward five key points to solve the problems. Results The medical insurance endows the medical records with new connotations, and has more requirements about the timeliness, the accuracy, completeness, integrality and the rationality of the documentation of the medical records. Conclusions We should develop the education about quality, train the staff members in documentation of the medical record, establish the standard of the medical record quality, improve the medical record quality control system, and strengthen the management of the medical record.