浅谈病案内涵质量监控——对疾病诊断的监控

Discussion on the Quality Control of Medical Records Content-Surveillance on the Disease Diagnosis

病案内涵质控是病案内容质量监控的要点、也是难点,本文通过对疾病诊断正确性的监控、对重要疾病漏诊的监控以及对疾病诊断名称书写正确性的监控,浅谈一些体会,加强病案质检员间的体会交流,有利于提高病案内涵质量。

For quality control of medical records,connotation is the main points of contents,and also a nodus.In this paper,the author discussed some experience on the aspects as following：monitoring the accuracy of diagnosis,surveillance on the misdiagnosis of major diseases,and how to control the correctness of the name writing of diagnosis,in order to strengthen the experience exchange about the quality control of medical records between members for improving the quality of medical records contents.