【摘要】 目的为了提高产科医疗质量,防范医疗纠纷,探索提高产科病案质量方法。方法设计《产科住院病历质控核对表》(简称《核对表》),比较核对表使用前后病历质量情况。结果核对表使用后,产科病案的终末质量检查结果显示,核对表使用后组的甲级病案率比使用前组高,两者差异有高度显著性(P<0.01)。结论核对表的使用将科室一级病案质量监控从定量变为定性,临床医师更容易掌握病历质控要点,大大提高了科室一级病案质量监控的成效。核对表有助提高产科病案质量。更多还原

【Abstract】 Objective To explore ways of improving the quality of obstetrical medical records,improve obstetrics medical service quality and prevent medical disputes.Methods Design the quality control check list of obstetrical medical records,compare the quality before and after the use of the check list.Results The quality of obstetrical medical records was obviously improved after using the check list.Conclusion The check list can improve the quality of obstetrical medical records.更多还原