摘要
目的针对病案首页填写缺陷,制定质量监控和改进措施。方法通过质量控制检查部门的检查修改和定期反馈检查,分析首页缺陷原因,提出改进措施并跟踪改进效果。结果病案首页缺陷明显减少,无缺陷病案首页从零提高到39.3%。结论提高病案首页填写质量,必须持之以恒地加强病案质量管理,必须增强医护人员的责任心,提高临床医师的业务素质。
Objective Through making quality control and improvement measures to reduce fill-in defects of the front sheet of medical record.Methods After inspecting and regular feedback checking,the quality control departments analyze the defects reasons of the front sheet of medical record,and suggest improvement measures and track improving effect.Results The defects of the front sheet of medical record reduced significantly,the front sheet of medical record which has no defects increased from 0% to 39.3%.Conclusion We should strengthen quality management of medical records constantly,enhance the responsibility of health care workers,and improve the professional quality of the clinician to improve the front sheet of medical record fill in quality.
出处
《中国病案》
2011年第4期17-18,共2页
Chinese Medical Record
关键词
病案首页
质量分析
控制措施
The front sheet of medical record
Quality analysis
Control measures
