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目的明确病案质量是关系到患者健康状况、是处理和解决医疗纠纷裁决鉴定部门用以判定责任的法律依据。方法加强对病历及时、准确、规范、书写的审核及质量监控,检查各项制度的执行情况。结果病案质量直接影响到医疗质量,对医院的医疗质量管理起着重要作用。结论病案质量监控在医院医疗质量管理中起着不可替代的作用。
The purpose of defining the quality of the medical record is related to the patient’s health condition and is the legal basis for handling and resolving the responsibility of the medical dispute arbitration appraisal department for determining the responsibility. Methods To strengthen the audit of medical records in a timely, accurate, standardized and written manner and the quality control, and check the implementation of various systems. Results The quality of medical records directly affects the quality of medical care, and plays an important role in the management of medical quality in hospitals. Conclusion The medical record quality control plays an irreplaceable role in the hospital medical quality management.