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目的通过对本院病案的内涵质量分析,探讨其缺陷的成因,研究其改进的办法;尽量减少病案质量缺陷的产生,确保病案的真实性。可靠性和完整性,促进病案管理质量的提高。方法对工作中常见的病案质量缺陷进行归类、统计、分析。结果发现病案首页、病历书写、各类检查结果单据、住院知情同意书等出现缺陷情况最普遍,是病案质量管理的难点。结论制定严格的病案质量管理制度,加强职业道德与法制意识的教育,提高病案书写人员业务水平,加强每个环节的管理,是提高病案内涵质量的有效办法。
Objective To analyze the connotation and quality of medical records in this hospital, to explore the causes of its defects, and to study its methods of improvement; to minimize the occurrence of medical record quality defects and ensure the authenticity of medical records. Reliability and integrity improve the quality of medical record management. Methods Classification, statistics, and analysis of the quality defects of common medical records in the work. As a result, it was found that the most common defects in the first page of medical records, medical records, various inspection results documents, and informed consent of hospitalization were the difficulties in quality management of medical records. Conclusion Establishing a strict quality management system for medical records, strengthening education on professional ethics and awareness of the legal system, improving the business level of medical record writers, and strengthening the management of each link are effective ways to improve the connotative quality of medical records.