病案管理质量控制系统的实施

Implementation of quality control in medical record management

在病案管理工作中建立了环节质量控制系统。将病案统计室的工作按先后顺序分为入院登记、病案整理、编目、统计分析、计算机录入、入库和供应７个工作环节，制定出各项工作操作规范及岗位责任制，将每个工作环节作为一个质量单位，每个岗位的工作人员在完成本职工作的同时负责检查、监督前一个环节的工作，由此形成了质量控制网；按各级检查程序分为基础环节、中间环节、主体环节等３个管理环节，组成了环节管理系统。这个管理系统的特点是：以岗位责任制为主导，加强了各项规章制度的落实；在质量第一的前提下，以基础环节的质量管理为重点，注重病案从整理到入库全过程的质量控制；所有工作人员人人参与，各尽其责，使质量控制措施得以落实。经过初步实践，做到了病案２４小时回收率为９６％，保证了病案在病人出院后６天能够正常借阅，进入短时、高效的工作状态。

The work in Medical Record Department can be divided into seven processes according to the work flow ,i.e.records assembling,classification,statistics and analysis,computer data input,filling and delivery.The manipulating regulations and post responsibility for each process should be made out.Each process is taken as a unit for quality control.While doing his/her own job,a staff should also take the responsibility to check and supervise the prior process. In this case a network of quality control has been formed . Quality assessment program composes of three parts of fundamental,medium,and main steps,those form the Process Quality Control System. The features of this system are to follow the regulations in the guidance of post responsibility and to emphasize the fundamental prior to other steps. Everyone in the department plays his/her role in the work of process quality control and has his/her own responsibility. The preliminary analysis revealed that a retrieved rate was 96%from discharged records attained in 24 hours,which enabled the record available in 6 days and made the department entering a status of high efficiency.