从终末病案检查记录中解析影响质控的歧义问题

Analysis of Ambiguity Problems of Affecting Quality Control in the Terminal Medical Record Examination Record

阅读某医院近两年的病案质控表,将所见产生歧义的问题,结合不同情况进行分析,给出质控分。结果发现一种问题在不同病案中分析各不同,质控亦有不同。解决歧义问题,首先,应养成全面精细化分析问题的习惯,认真登记质控表,才能使质控工作有针对性;此外,为针对性地公平、公正的质控病案,有必要对中医、中西医结合病案质量查评价用表进行精细化。

To read the medical record quality control chart of a hospital in the past two years, and to analyze the problems in different situations and to give the quality control points. The results showed that a problem was analyzed in different cases, and the quality control was also different. To solve the ambiguity problem, first of all, should develop a comprehen-sive fine analysis of the habit, the registration table to make serious quality control, quality control work targeted; in addi-tion, for the quality control of medical record to fairness and justice, it is necessary to check the evaluation table of fine Chinese and Western medicine with the quality of medical records.