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目的提高医院病案管理质量,使病案管理更加规范,规避其中的风险。方法按ISO9001质量管理体系要求编制病案管理作业指导书和程序文件,将病案管理的质量要求分解并贯穿于工作流程的每个环节。结果从2002年1月至2005年12月引入ISO9001质量管理体系后共有住院病案50,622份,主要管理指标均达到100%,及时准确地为临床、教学、科研、处理医疗纠纷和社保等提供病历资料。体会转变观念,做好病案质控工作,完善病案归档管理,建立病案室与其他各科的沟通与互动,坚持持续改进,促进病案管理质量提高,有效防范了因病案质量管理不规范带来的各种风险。
Objective To improve the quality of hospital medical records management, make medical records management more standardized, and avoid the risks involved. Methods According to the requirements of the ISO9001 quality management system, medical records management work instructions and procedure documents were prepared, and the quality requirements of the medical record management were decomposed and run through every link of the workflow. Results From January 2002 to December 2005, a total of 50,622 inpatient cases were introduced after the introduction of the ISO 9001 quality management system. The major management indicators reached 100%, providing medical records in a timely and accurate manner for clinical, teaching, scientific research, and handling medical disputes and social security. . Learned to change ideas, do quality control of medical records, improve medical records management, establish communication and interaction between the case room and other departments, persist in continuous improvement, promote the improvement of the quality of medical record management, and effectively prevent the unsound quality management of medical records. Various risks.