医疗过失病案审核的重点

The Key Point of Medical Records Examination and Verification in Medical Negligence

通过医疗纠纷病案的有效内部审核,评价诊疗过程的符合性和有效性。对医疗纠纷病案采取诊疗过程的正向审核方法,对其诊疗过程的审核重点在于落实核心制度的基础上对问诊、查体过程、辅助检查过程、治疗方案符合性及治疗方案的实施、调整和更改而需要采取的措施等项目的审核。为院方采取有效纠正和预防措施,避免医疗纠纷的发生提供依据,对提高病案质量具有重要的现实作用。

Through effective internal examination and verification of medical records in medical tangle,we evaluate conformance and efficiency during cure and treatment.Applying positive examination and verification during cure and treatment,this article puts forward the key point of it during cure and treatment is that based on core system implement to examination and verification of inquiry,examination process,auxiliary check process,treatment plans conformance and countermeasures because of implement,adjustment and alteration of treatment plans.It provides basis for hospital applying effectively correction and prevention countermeasures and avoiding medical tangle,which plays important reality role for medical records quality improvement.