【摘要】 目的总结病历书写评比和技能比武活动的做法和体会,探索改进方法,提高病历书写质量合格率。方法随机抽取病案,专家分工,流水作业评价,设定权重系数。结果甲级病案率97.1%,病案合格率90.1%。结论病历书写要不断持续改进,开展教育和培训,才能达到要求。更多还原

【Abstract】 Objectives To summarize the practice and experience of comparison and appraisal to the medical record writing and skill activities;to explore improved methods;to raise qualification rate of medical record writing.Methods select medical record randomly for specialists to evaluate them seperatively and rotately by setting up weight coefficient.Results first degree rate of medical record is 97.1%;qualification rate is 90.1%.Conclusions In order to achieve the goal,medical record writing needs to improve continually by carrying out education and training.更多还原