中医病案环节质控与质量改进方法探讨

Study on Multi-step Quality Control and Quality Improving Methods in the Medical Records Management of Traditional Chinese Medicine

目的加强医疗质量控制,探讨病历书写质量和管理的改进方法。方法以中医医院运行病历的质控为切入点,明确环节质控的主要内容,剖析病历书写中存在的主要问题。结果提出依法质控,必须加强对运行病历的实时监控。结论完善以病区质量监控为基础、环节质量监控为重点的过程监控方式的质控模式,落实病历书写的客观性、真实性、及时性和完整性,对提高病历质量、防范医疗纠纷起到了积极作用。

Objective To enhance the quality control of medical services, and probe into the quality improving methods for medical records writing and management; Methods we took the quality control of medical records in a Traditional Chinese Medicine（TCM）hospital, identified me major content of multi - step qUality control, and analyzed the chief problems in medical records writing. Results During the process of implementing qUality control according to law, the hospital should strengthen the real - time supervision on medical records. Conclusion Refining the quality control model as monitoring the whole process, which is based on the quality monitoring in each ward and focus on the sectional quality monitoring, ensuring the medical records are written objectively, authentically, timely and completely, play a positive role in improving the quality of medical records, as well as in taking precautions against medical disputes.