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病案质量管理是医院医疗质量管理的重要组成部分,随着《中华人民共和国执业医师法》、《医疗事故处理条例》、《医疗机构病历管理规定》及《病历书写基本规范(试行)》等法律法规的颁布实施,给病历书写质量管理提出了更高的要求,但目前,仍有部分医护人员对病历书写不够重视,病历的客观性、真实性、准确性及完整性落实不够,患者的知情同意权不能充分体现,给医疗纠纷造成很大隐患,我院通过建立健全病历全程立体式质控网络,对住院病历形成的全过程实行全方位质量控制,使我院的住院病历质量有了明显提高。
The quality management of medical records is an important part of hospital medical quality management, along with the Law of the People’s Republic of China on Practitioners, the Regulations on the Handling of Medical Accidents, the Regulations on the Management of the Medical Records of Medical Institutions and the Basic Rules for the Writing of Medical Records (Trial) and other laws The promulgation and implementation of laws and regulations put forward higher requirements for the writing quality management of medical records. However, at present, there are still some medical personnel who do not pay enough attention to the writing of medical records, and the objectivity, authenticity, accuracy and completeness of the medical records are not sufficiently implemented, and the patient’s knowledge is not enough. The right to consent can not be fully reflected, causing great potential for medical disputes. Our hospital has established a full-scale three-dimensional quality control network for medical records to implement full-scale quality control over the whole process of inpatient medical record formation, which has made our hospital’s inpatient medical record quality clear. improve.