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本文主要阐述某院在卫生部第二轮医院评审期间,严格按照《三级综合医院评审标准实施细则》要求,通过自查及科室反馈查找病案管理工作中存在的问题,如遗漏填写转科病历交接表、漏签知情同意书、遗失病历资料等情况,并通过采取相应的措施,加强病历质量三级质控关,重点审查危重症患者病案以及总结改进等方式减少或避免问题的发生,以此提高病案质量,促进医院整体医疗质量的进一步发展。
This paper mainly expounds a hospital in the second round of the Ministry of Health Hospital review period, in strict accordance with the “three general hospital review criteria for the implementation of” requirements, through self-examination and department feedback to find medical records management problems, such as omissions to transcribe medical records Transfer form, informed consent form, medical records, etc., and through the corresponding measures to strengthen the three quality control of medical record quality, focusing on reviewing the critically ill patients and summarize and improve the way to reduce or avoid the occurrence of the problem, This raises the quality of medical records and promotes the further development of the overall medical quality in hospitals.