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目的总结病历书写评比和技能比武活动的做法和体会,探索改进方法,提高病历书写质量合格率。方法随机抽取病案,专家分工,流水作业评价,设定权重系数。结果甲级病案率97.1%,病案合格率90.1%。结论病历书写要不断持续改进,开展教育和培训,才能达到要求。
Objective To summarize the practices and experiences of medical records writing competitions and skills contest activities, explore ways to improve and improve the passing rate of medical records writing quality. Methods randomly selected medical records, expert division of labor, assembly line evaluation, set the weight coefficient. Grade A case rate of 97.1%, medical record pass rate of 90.1%. Conclusion Medical records writing should continue to improve, carry out education and training in order to meet the requirements.