论文部分内容阅读
目的:对该院呼吸内科住院病案书写进行改进,观察改进后病案书写质量。方法:按照2010年山东省卫生厅颁布的《病历书写基本规范》要求及枣庄市病案管理质量控制中心制定的《住院病案(终末)质量控制标准》对终末病案进行考评,并根据考评情况提出改进措施,再次对病案进行考评,对比前后病案质量变化。结果:2014年3月~5月和2014年9月~11月该院呼吸科住院病案分别为298份和307份,甲级病案率分别为89.2%和97.8%。结论:我科根据病历检查情况进行有针对性改进后,住院病案质量有明显提高。
Objective: To improve the inpatient medical record of respiratory medicine in the hospital and observe the quality of the improved medical record. Methods: According to the requirements of “Basic Medical Records Writing” promulgated by Health Department of Shandong Province and the “Quality Control Standard of Inpatient Medical Record (Final)” formulated by Zaozhuang Medical Records Management Quality Control Center in 2010, Put forward improvement measures, again review the medical record, compare the quality of the medical record before and after the change. Results: From March to May 2014 and September to November 2014, the inpatient respiratory department inpatient cases were 298 and 307, respectively, and Grade A cases were 89.2% and 97.8% respectively. Conclusion: According to the records of our department to conduct targeted improvements, the quality of hospitalized cases significantly improved.