摘要
目的提高归档病案质量,加大环节质量监控措施,强化各级医师质量意识。方法随机抽查归档病案1030份,根据省卫生厅下发《医疗文书规范与管理补充规定》标准要求进行检查。结果 1030份归档病案中,未严格按标准要求书写63份,占6.1%。结论加强对归档病案质量监控、规范医疗文书书写,是确保医疗安全、减少医疗纠纷的首要前提。
Objective To improve the quality,strengthen the link filing medical quality control measures and strengthen various physicians quality consciousness.Methods Spot-check archive records 1030 copies were randomly chosen,according to the provincial health bureau issued the standard and the management of medical documents supplementary provisions of standard requirement for inspection.Results 1030 of filing medical record not strictly in accordance with the standards of writing 63,accounting for 6.1 percent.Conclusion To strengthen filing medical quality monitor,standardizing medical documents writing,is premise to ensure medical safety and reduce the first premise of medical disputes.
出处
《当代医学》
2011年第16期34-35,共2页
Contemporary Medicine
关键词
归档病案
质量缺陷
环节质控
质量意识
Archiving records
Quality defects
Link quality control
Quality consciousness
