加强运行病历质量监控的做法与体会

Practice and Experience of Strengthening Quality Control of Medical Records in ward

目的强化运行病历质量管理,提高医疗质量。方法确定运行病历实时监控的内容并适时调整,制定临床科室运行病历考核标准,将运行病历的质量考核结果与科室医疗质量综合考评挂钩。结果围手术期病历质量及内科系统慢性病人病历管理应引起重视。结论对运行病历实行实时监控,在不同阶段根据出现的不同问题及时调整监控内容及方法,促进病历质量的持续改进。

Objective To strengthen the management of medical records quality and improve medical quality. Methods We determined the content of real-time monitoring medical records in ward and made timely adjustment, developed standards for assessing medical records, and linked medical records quality to the comprehensive evaluation of medical quality of departments. Result The quality of perieperative medical- records and roanagement of patients＇ medical records with chronic disease should be paid attention.Conclusion To carry out the real-time mornitoring of medical documentation so that the quality control methods can be adjusted for problems in each stage in ward.