摘要
目的通过运行病历质量监控,提高病案书写质量。方法对3000份运行病历进行质量监控并对存在的缺陷进行统计分析。结果缺陷病案1134份,其中缺陷项目共3360项,平均1.12项/份。结论运行病历是病案质量监控的关键,要把病历缺陷消灭在萌芽状态,才是保证终末病案质量的有效措施。
Objective To improve the writting quality of medical records through data quality monitoring. Methods To make quality monitoring on 3000 eases of running medical records and conduct a statistical analysis on the defect items. Results There were 1134 cases of medical records existing defects, and 3360 defect items, the average number was 1.12 per case. Conclusions The run- ning medical records were the key of quality minitoring of medical records, only through effective measures to eliminate the defects of medical record thoroughly, can we able to guarantee the quality of terminal medical records.
出处
《中国病案》
2013年第8期18-19,17,共3页
Chinese Medical Record
关键词
病案
缺陷
运行病历
环节质控
Medical records
Defects
Running medical records
Links quality control
