从案例分析中引发病案终末质控的思考

Thinking of Final Quality Control of Medical Records Based on Case Analysis

目的增强医务人员法律和责任意识,改进病案三级质控方法 ,促进病案质量及医疗安全水平的提高。方法选择与病案相关的纠纷案例,对现行病案质控方法从法律和安全层面进行分析与思考。结果病案终末质控中病案返修问题存在着严重的安全隐患,而此问题尚未得到医政管理同仁的高度重视。结论依法制定科学的病案质控和质量评价体系、加强法制教育和环节病案质量管理已经成为医政管理的当务之急。

Objective To enhance the law and responsibility awareness of medical personnel and improve the method of three-level medical records quality control for promoting medical records quality and medical safety.Methods Dispute cases related to medical records were selected and existing methods in the quality control were analyzed and investigated from law and security aspects.Results Medical records returned for modification had serious security risk in the final quality control,which had not been attached great importance by medical affairs managers.Conclusion It＇s becoming an urgent task in medical management to establish a scientific quality control and evaluation system according to law and strengthen legal education and link quality management of medical records.