浅析医院三甲复审中病案管理存在的问题与措施

Problems and Measures of Medical Record Management in Grade 3 and First Class Hospital Review

本文主要阐述某院在卫生部第二轮医院评审期间,严格按照《三级综合医院评审标准实施细则》要求,通过自查及科室反馈查找病案管理工作中存在的问题,如遗漏填写转科病历交接表、漏签知情同意书、遗失病历资料等情况,并通过采取相应的措施,加强病历质量三级质控关,重点审查危重症患者病案以及总结改进等方式减少或避免问题的发生,以此提高病案质量,促进医院整体医疗质量的进一步发展。

Our hospital strictly in accordance with the requirements of the review and find problems of medical record management by self-inspection and department feedback during the period of grade 3 and first-class hospital review. The problems are such as missing fill in change medical records transition table, missing sign the informed consent, medical records 10st and so on. We strengthen level 3 quality control of medical record By taking corresponding measures, especially the medical records of critically ill patients to avoid problems and improve the quality of medical record finally promote the further development of the overall medical quality of hospitals.