摘要
实施病历缺陷管理主要是为了控制病人在住院（留观）期间的诊断、治疗、手术、抢救、医院内感染、护理、营养、病历书写等方面的缺陷。该病历缺陷判定标准共分8个方面104条。通过对2007年1—3月54份出院（观）病历进行质量评价，结果验证用这种方法进行病历质量管理是检衡医疗护理质量很好的控制手段。既评价了病历的质量，又掌握了医疗质量问题的动态情况，为减少医疗差错．提高医疗质量，保证医疗安全提供了重要的提示性管理方法。
A series of medical defect assessment criteria, 104 items in eight categories, were used in 54 in- patients treated by the hospital, for examining defects in quality of medical services, such as diagnosis , treatment , operation , nosocomial infection control , nursing care, casenotes ; and were found to be useful in helping to reduce the incidence of medical negligence , ensure safety and improve quality in medical treatment.
关键词
病历缺陷
对策
医疗质量
医疗安全
Quality of medical Services in medical Treatment Defects in medical services
