摘要
目的了解病历环节质量现状,分析运行病历存在的缺陷,探讨提高病历环节质量的有效方法。方法随机抽查2008年1月至2009年12月临床各科运行病历1920份进行缺陷分析。结果 1920份运行病历中,优级病历1754份,占91.4%,良级病历166份,占8.6%,无丙级病历。结论重视运行病历的规范化管理,是保证医疗质量,确保医疗安全的前提。
Objective To understand the status of link quality of medical records,analyze the deficiencies in medical records and investigate effective strategies to improve link quality.Methods Deficiencies were classified and analyzed on 1920 medical records randomly selected from each clinical department from Jan.2008 to Dec.2009.Results There were 1754（91.4%）excellent medical records in 1920 medical records,166（8.6%）good medical records and no C medical records.Conclusion It＇s necessary to attach great importance to standardize the management of medical records and improve writing quality,which is the premise to ensure medical quality and medical safety.
出处
《中国病案》
2010年第7期27-28,共2页
Chinese Medical Record
关键词
运行病历
环节质量
Medical records
Link quality
