规范化病案管理是提高病案质量的关键

The Promotion for Medical Record Quality through Norm of Medical Record Management

目的通过对病案流程中各环节的规范化管理以提高病案的工作质量。方法建立健全病案管理规章制度,规范病案管理各环节工作,加强岗位职责,保障病案回收、归档的完整性和及时性。结果规范化的管理增强了病案管理人员责任意识和法律意识,每个工作流程都有章可循,约束了职业行为,减少了差错。结论科学、合理、有效、规范地开展病案管理工作是确保每一份病案质量的关键。

Objective Through norm management of segment in medical record process to improve work quality of medical record.Methods To set up sound rules and regulations of medical record;to standardize segments of medical record management;to strengthen staff responsibilities;to ensure the completeness and timeliness of medical record recovery and filing.Results The management standardization can strengthen responsibility and law consciousness of medical record management staffs,restricting profession behavior and reducing mistake,which makes every work process have rules to follow.Conclusion The key of ensuring every medical record quality is that develop medical record management scientific,rational,effective and standard.