从病历质量分析医疗制度执行的问题与对策

Improvement of Medical Regulations Executing by Medical Record Quality Management

目的通过病历质量检查,查找医疗过程中医疗核心制度执行中存在的问题,提出改进对策。方法从出院病历中随机抽取满足病危病重、住院超过30日以上、死亡等条件的病历进行分析评价。结果三级查房制度、术前讨论制度、告知知情同意制度、医嘱制度的缺陷率较高。结论应通过教育培训、监督检查、与个人绩效考核挂钩等多种途径和方式,提高各级医师对医疗核心制度的执行力。

Objective By examining medical record quality, the problems in executing medical core regu- lations in medical process were analyzed, and countermeasures were put forward. Method Cases were randomly selected in those who died in the hospital, and were with serious ill, and stayed in the hospital more than 30 days. Results The defect rates of three - level ward round system, preoperative discussion system, informed consent system, doctors＇ advice system were higher. Conclusion We can improve the executive forces of physicians at all levels through various kinds of ways and methods, such as education and training, supervision and inspection, and set relative item in personal performance appraisal.