以主治医师查房考核为契机提高病历质量

Through Checking the Quality of Ward Round by Attending Doctor,Improve the Quality of Medical Record

目的以主治医师查房考核为契机,提高病历质量。方法从临床诊治情况、运行病历质量、规章制度落实、临床路径、查房基本要求及患者调查等方面考核主治医师查房,对运行病历质量相关问题进行总结分析。结果主治医师查房水平影响病历质量。结论建立主治医师查房考核制度,促进病历质量提升。

Objective Through checking the quality of ward round by attending doctor,improve the quality of medical record.Methods A set of quality standards for ward round by attending doctor were formulated.In the inspection process of ward round by attending doctor,the problems on medical record were found and analyzed.Results The levels of ward round by attending doctor affect the quality of medical record.Conclusions The relevant inspective regulations of ward round by attending doctor should be established that promote the quality of medical record.