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本文分析了新时期病案质量管理的特点,提出了应对措施。指出新形势下病案质的提高不能仅仅依靠质检室的把关,更不能依靠病历返修。而应该根据新形势的发展,将医疗质量与病案质量结合起来,将环节质量检查与终末质量检查结合起来,通过医疗质量的提高来促进病案质量的提高。同时强化医务人员的法律意识,促使其自觉地写好病历。上级主管部门在行业检查时也应将环节质量检查纳入考核的重点。这样可从根本上杜绝返修病历现象,促进病历内在质量的提高。
This article analyzes the characteristics of the quality management of medical records in the new era and proposes countermeasures. It is pointed out that the improvement of the quality of illness under the new situation cannot rely solely on the check of the quality inspection room, and it cannot rely on the medical records to be repaired. However, according to the development of the new situation, the quality of medical care should be combined with the quality of medical records, link quality inspection and final quality inspection should be combined, and the quality of medical records should be improved through the improvement of medical quality. At the same time, it strengthened the legal awareness of medical personnel and prompted them to consciously write medical records. The higher authorities should also incorporate the link quality inspection into the assessment focus during the industry inspection. This can fundamentally eliminate the phenomenon of repairing medical records and promote the improvement of the internal quality of medical records.