病案内涵质量主要存在问题及对策探讨

MAJOR PROBLEM IN THE CONTENT QUALITY OF MEDICAL RECORD AND THEIR COUNTERMEASURES

提出病案内涵质量体现病案记录的科学性、准确性、及时性以及目前病案内涵质量主要存在问题。提出通过修订质控标准,实行临床住院医师到病案室轮转培训及进修医师岗前培训,加强环节质控,开展质量考核等对策,提高病案内涵质量。

The content quality of medical record reflects it's scientificalness, accuracy, and timeliness. The article presents the major problems in the content quality of medical record at prescnt, and suggests promoting the quality by means of revising the quality control standards of medical record, carrying out training in rotation at the department of medical record for clinical residents and further training for graduate physicians before practice, enhancing staged quality control, and organizing quality examinations.