以科级质量管理为基础的病历质量考评机制建立

Medical Records Evaluation Mechanism Based on Quality Control at Department-level

随着医院业务量不断的增长,三甲医院疑难杂症越来越多,出现了病历质量考评覆盖率降低、病历检查专家对专科病历内涵质量不够深入等问题。原有的病历质量考评模式,不能客观反映病历质量情况。建立以科级质量管理为基础的病历质量考评机制,可提高科室及全员病历质量考评参与度、加强科级质量管理能力,不断提升医院病历质量内涵。

Since business volume is rocketing and rare illnesses are increasing in tertiary hospitals, the coverage rate of medical records evaluation is dropping and experts specializing in medical records examination lacks a deep un- derstanding of quality connotation of medical records. The medical records evaluation mode leaded by the old functional departments like medical administration department is not working properly now. The paper proposes medical records evaluation mechanism based on quality control at department-level should be established to improve the degree of participation of department-level and all staff medical records evaluation, to strengthen the department-level quality control management ability, and to enhance the connotation of hospital medical records quality.