病案质量管理内容与方法的建立和应用

Establishment and application of the contents and methodology by means of a quality control of medical record

随着医院的现代化建设和管理进程的向前推进,对病案质量管理内容与方法提出了新的标准和要求。从医院管理和医疗质量管理的高度逐步建立了病案质量管理的具体内容和方法,使我院病案质量有了明显提高。我院病案质量管理工作的建立可归纳为三个阶段:一、医院病案质量检查小组建立初期的工作;二、甲级病案率达标后的思考与工作;三、通过“三甲”评审后的思考与工作。其中包含二十一条病案质量管理的内容与方法。

Accompanied by the rapid progress of the modernized construction and management of the hospital, new criteria and demand of contents and methods in the quality control of the medical records were suggested. According to the necessity of the situational changes, concrete contents and methods in the quality control of the medical records were built up gradually in order to reach theheight of excdllent medical quality of the hospital, they were applied in the clinic and the quality of the medical records in our hospital were greately improved. The establishment of the quality control of the medical records in our hospital included 3 stages: 1. The initial work after the set - up of the checking - group for the quality control of the medical records. 2. The thinking and word after the percentage of grade 'A' medical records had reached the criteria. 3. The thinking and work after 'San - Jia' (three grade 'A') had passed the judgement including 21 kinds of contents and methods of the quality control for the medical records.