摘要
目的通过剖析传统病案质控的局限性,介绍如何构建分级精细化质控体系及其科学性。方法分解卫生部《病历书写基本规范》评分标准,制作成四个级别的质控标准对病案进行分级质控,分层面找出各级的缺陷重点,有针对性进行突破。结果以卫生部的《病历书写基本规范》)作终末质控,评价结果缺少针对性;而采用分级精细化标准评价,可分级判别病案具体缺陷。结论分级精细化病案质量监控从完整性、内涵性、专项性、医学逻辑性四个方面更加深入,可以找出病案具体缺陷,有针对性地给予临床医生建议。
Objective To introduce how to establish classification refine standard in the quality control system of medical records and its science through analyze the limitation of traditional quality control methods. Methods To decompose the score standard of ＂Writing Basic Rules of Medical Records＂ made by the Health Ministry to form four grades standard and conduct classification quality control to the medical records according to it. Then find out important defects in each level and try to make a breakthrough specifical- ly. Results It may lead to biased result if single assessment standard is used for final medical record control, but we can distinguish the specific defects of different levels with the application of classification refine standard. Conclusions Classification refine standard quali- ty control system is better from aspects such as integrity, connotation, specialty and medical logicality, thus to find out the specific defects of the medical records and provide suggestions for the clinical doctors specifically.
出处
《中国病案》
2013年第6期25-26,M0002,共3页
Chinese Medical Record
关键词
分级质控
分解细化
深入评价
Classification quality control
Discompose refining
Further assessment
