医院病历质控体系构建的创新思路与实践

Innovation and Practice of Medical Record Quality Control System

分析了当前各医院病历质控体系中存在的主要问题,提出病历质控体系设计应当遵循随机化、公开化和责任化3个原则。从6个方面介绍了医院构建基于两级随机盲态设计的病历质量控制体系的创新思路与具体实践。在体系中围绕"能够负责、敢于负责、必须负责"3个方面建立了科学严谨的责任落实保证机制,确保了新的体系高质量的常态化运作。用公平、公正、公开以及具有刚性和辅以适当奖惩措施的质控结果,有效促进了病历质量和医疗服务质量的持续提升。

The paper analyzes the main problems existing in the current hospital medical record quality control system,and puts forward that the design of medical record quality control system should follow the three principles of randomization,publicization and responsibility.At the same time,the paper also introduced innovative ideas and practice of medical quality control system from six aspects.From ＂to be responsible,dare to be responsible,and must be responsible＂,a scientific and rigorous assign responsibilities guarantee mechanism is established.The open,fair and rigid quality control result,with the appropriate incentive measures,can effectively promote the continuous improvement of medical quality and medical service quality.