壮医病案质量标准和管理体系建设实践

Exploration on the Quality Standard and Management System of Medical Records in Zhuang Medicine

通过分析广西某新建三级公立民族医医院建院初期病案管理现状、壮医病案质量标准和管理体系建设的经验,规范壮医病证和诊疗技术名称,编制壮医病证名称分类与代码、壮医病历书写基本规范和住院病案首页填写质量规范,建立壮医病案模板和壮医病案质量标准,使病案充分反映壮医辨证思维理念。构建以壮医病案内涵质控为核心、三级质控为架构、院科互动的壮医病案质量管理体系,在医疗质量形成过程中实行有效的质量控制,加强壮医内涵,确保医疗质量,有效促进临床诊疗水平不断提高,更好的传承与促进壮医药事业发展。

By analyzing the current situation of medical record management during the early stage of the establishment of a new tertiary public Zhuang Medical Hospital in Guangxi, this paper introduces the experience and practice of the quality standard and management system construction of Zhuang medical records;standardizes the name of Zhuang medical diseases and treatment technology;compiles the code of Zhuang medical diseases and classification names, the basic specifications for writing Zhuang medical records and the quality specifications for filling in the medical record front pages;establish the medical record template and quality standard of Zhuang medicine so that the medical record can fully reflect the dialectical thinking concept of Zhuang medicine. It is necessary to build a Zhuang medical record quality management system with the core of connotation quality control of Zhuang medical records, the structure of three-level quality control and hospital department interaction, in order to implement effective quality control in the formation process of medical quality, strengthen the connotation of Zhuang medicine, ensure the quality of medical treatment, effectively promote the continuous improvement of clinical diagnosis and treatment level, and better inherit and promote the development of Zhuang medicine.