病案环节质量控制中的书写要求控制

Control of Writing Requirements in Quality Control of Medical Records

随着现代医院的开展成为不可阻挡的趋势,对病案的管理也提出了新的要求。但在实际工作中,病案质量低的问题非常突出,造成病案书写记录的规范性、及时性、完整性、真实性等存在很大问题。病案环节质量控制中的书写要求控制注重把持续改进理念贯穿诊疗行为始终,通过理念转变促习惯养成,力促形成和主动适应质量运行新常态。本文首先概述了医院病案管理的内容与意义,分析了医院病案管理书写要求控制存在的问题,探讨了病案环节质量控制的含义,最后提出了相关对策:建立全院性的质量控制体系、严格落实质量管理规章制度和积极建立电子病案体系。

With the development of modern hospital become an irresistible trend,the management of medical records also put forward new requirements. But in the actual work,the problem of low quality of the medical record is very prominent,which caused the standard,timeliness,integrity and authenticity of the record of the medical record writing. Writing medical record link quality control requirements control focus on continuous improvement philosophy through diagnosis and treatment behavior always,through the change of the idea of promoting habits,urged the formation and take the initiative to adapt to the new normal operation quality. This paper begins with an overview of the hospital medical record management content and significance,analysis of the hospital medical record management writing requirements control problems,discussed the meaning of medical record quality control link,and finally puts forward some relevant countermeasures： establishing the whole hospital quality control system,strictly implement the quality management rules and regulations,and actively establish electronic medical record system.