【作者】 李晓晴； 王岐山； 郭剑； 杨侠；

【Author】 Li Xiaoqing;Wang Qishan;Guo Jian;Yang Xia;The Department of Quality Control of Shaanxi Provincial People’s Hospital;

【机构】 陕西省人民医院质控科；

【摘要】 目的加强手术科室运行病历质量管理,提高病历质量。方法制定术前病历质量监控表,在手术室对运行病历质量进行监控。结果核心制度落实不到位,术前检查不完备,无效知情告知等。结论应进一步加强医师医疗核心制度的培训和监督落实,提高围手术期病历质量,确保医疗安全。更多还原

【Abstract】 Objective To improve the quality of the medical records by strengthening the management of running medical records quality at Surgical departments.Methods To work out quality form of peroperative medical records for monitoring the medical record quality in the operating rooms.Results Unfavorable implement of medical core system;incomplete peroperative examination:invalid informed told.Conclusion This article suggests that should further strengthen doctors medical core system training and supervision for improveing quality of preoperative medical record and ensuring medical safety.更多还原