住院病案质量管理的探索

Exploration on Quality Management of Medical Records

从质控医师的产生、职责、考核;运行病案的人工质控、软件质控;住院病案的全面普查、重点核查、交叉互查;以及医务科的协调、指导等四个方面对住院病案的质量控制进行了一些新的探索。逐步形成了人工检查、软件督查、全面普查、重点核查、交叉互查(五查);限时整改(一改);医务科汇总(一汇总)的管理体系。

To explore the quality control of medical records from four aspect such as quality control doctors, responsibilities and regular check, human power quality control and software quality control of running medical records, comprehensive inspection, focus on examination and cross-check of hospital medical records, and coordination and guidance of medical department. Gradually formed a management system of human power quality control, software quality control, comprehensive inspection, focus on examination and cross-check （five checks）, limit rectification （one rectification）, Medical department summary （one summary）.