提高运行病历网上质控问题修改合格率

Improvement of the Modification Qualified Rate of Medical Records on Quality Control Problems

临床医师忽视质控问题,不及时修改并完善病历资料,是导致病历文书出现实质性错误的主要原因。开展QCC活动,运用PDCA循环促进质量持续改进。通过改进质控信息软件,加强与临床科室沟通交流,扩大培训范围及丰富培训形式等,提高了运行病历网上质控问题修改合格率,进一步保障了病历质量。

Clinicians ignoring quality control problems and delayed updating medical records are the main reasons for the obvious substantive errors in medical records. The QC group activities were carried out by using PDCA method for continuous quality improvement. By improving the quality control information software, strengthening communication with the clinical departments, and enriching the scope and form of training, etc., the modification qualified rate of medical records on quality control problems was improved, and the quality of medical records was further protected.