【摘要】 目的加强病案管理及病案书写质量监控,提高病案内涵质量。方法分析总结2008年1月-10月456份出院病案终末质量监控发现的问题,完善病案管理规章制度,建立病案质量三级检查体系和奖惩制度,评选优秀病案进行展览。结果病案质量有了明显提高,各级医师提高了病案书写规范的认识。结论病案管理是医院管理中一项非常细致的工作,提高病案质量需要各级领导的高度重视和互相配合,提高医务工作者的责任心和专业知识,增强法律意识,严格执行奖惩制度。更多还原

【Abstract】 Objective to strengthen medical records management and medical records writing quality control for improving medical records quality.Methods to analyze and summarize the existing problems in 456 final medical records from January to October in 2008,perfecting medical records management rules and regulations and setting up three levels system and rewards and punishment system of medical records quality,exhibiting excellent medical records as well.Results medical records quality have been improved obviously;doctors improved the knowledge about medical records writing standard.Conclusions medical records management is a very careful job in hospital management.The medical records quality improvement requires bosses at all levels highly value and cooperation,medical staffs responsibility and professional knowledge,law consciousness strengthening and strict system of rewards and penalties.更多还原