| 加强病历书写的质量监控确保病案质量 |
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| 引用本文： | 邢庆芳,张红霞,古莲香,姚馨荞.加强病历书写的质量监控确保病案质量[J].中国病案,2008,9(2):17-18. |
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| 作者姓名： | 邢庆芳 张红霞 古莲香 姚馨荞 |
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| 作者单位： | 广东省深圳市龙岗区人民医院信息科,深圳市,518172 |
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| 摘 要： | 目的针对住院病案缺陷的常见原因，提出解决方法。方法对2007年上半年出院病案进行质量检查。结果抽查病历924份，病历缺陷924份，共2540项次。结论加强医师的法制观念，加强责任感，强化基本功讪练，实行病案质量四级监控，杜绝缺陷病案归档上架，确保病案质量。
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| 关 键 词： | 病案 缺陷 质控 |
Strengthening the Control of the Quality of the Medical Record to Prevent the Deficiencies in the Documentation of the Medical Record |
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| Xing Qingfang,Zhang Hongxia,Gu Lianxiang,Yao Xinqian.Strengthening the Control of the Quality of the Medical Record to Prevent the Deficiencies in the Documentation of the Medical Record[J].Chinese Medical Record,2008,9(2):17-18. |
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| Authors: | Xing Qingfang Zhang Hongxia Gu Lianxiang Yao Xinqian |
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| Affiliation: | (the Department of Information of People＇s Hospital of Longgang District, Shenzhen City, 518173 ) |
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| Abstract: | Objective Advancing the resolutions,aiming at the causes of the deficiencies in the medical records.Methods To Inspect the quality of the medical records of the discharged patients from January to June in 2007.Result 924 medical records were investigated and all of them were with deficiencies,and there were 2540 items of altogether.Conclusion We should strengthen the senses of legality and responsibility of the doctors,and intensify the training of the basic skill,monitor the quality of the medical records in four levels,and put an end to file the medical records with deficiencies,to insure the quality of each medical record. |
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| Keywords: | medical record Deficiency quality control |
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