实施病例缺陷管理 提高医疗质量——对吉林省65所医院2180份病例缺陷情况分析

Decreasing Defects in Medical Records and Improving Services Quality

对吉林省65所医院的2180份病例进行了分析,结合实际,针对病例缺陷问题提出了加强质控,完善病例缺陷管理的对策:巩固医院分级管理及评审成果,防止评审后医疗质量滑坡;将病例缺陷管理纳入医院评审工作中,常抓不懈;卫生行政部门要加强管理,使医院分级管理及评审工作落到实处;规范标准,切实抓好医疗质量;继续坚持“病人第一,质量第一”的原则。

Defects found in medical records of 2, 180 cases from 65 hospitals in Jilin Province were researched from a number of perspectives: theoretical and methodological approaches to appropriate handling of relationship between time and labour saving vs suitability and reliability for no loss and a correct expression of important information contents; incorporation of relevant expertises into professional, vocational, and relating knowledge edeucation; improvement of quality of medical records as concrete examination and work targets in hospital stratified management and hospital accreditation; strengthening of regular guidance, management, experience and achievement summation to achieve what the respective levels of hospital information system could reasonably be expected to provide.