病案质控中存在问题的原因与改进措施

The Existing Problems in the Quality Control of the Medical Record,their Causes and the Countermeasures to Solve them

目的提高病案质控效能,确保病案质量。方法通过病案全程质控找出存在的问题,分析产生的原因,制定改进措施。结果质控方法存在表面化、形式化、职责不清、奖惩不利、行政误导等,应采取全程性病案质控机制。结论病案质控管理中,由终末质控为环节质控,抓好全员质量教育,树立法制观念,实施责、权、利明确的质控逐级负责制,认真落实病案质控措施。

Objective To improve the effectiveness of quality control of the medical record and ensure the quality of the medical record. Methods We analyzed the causes of the problems in the medical records and formulated measures for their improvement through the whole course quality control of the medical record. Resets Because of becoming surface, formulation, confused responsibilities, unfair system of rewards and penalties, and the misleading in management in the quality control, we should take the whole process quality control. Conclusions In the quality control of the medical records, the terminal quality control should be changed into link control. We should educate the whole staff members in quality control, to enhance their legal sense, and implement the responsibility system in different levels in quality control, step by step, with clear responsibility, power, and interests.