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为了统一病历书写格式和提高病历质量,我院于1982年6月开始,试行“临床军医病历质量检查评分标准”。通过半年多的实践,全院的病历质量显著提高,得到上级的好评。在去年军区后勤卫生部组织的师医院医疗质量大检查中,我院得分为全区第一名。今年,军区后勤卫生部又把我院“临床军医病历质量检查试行评分标准”作为全区师医院部分医疗质量检查评分标准和方法试行方案之一。从实践中我们感到,病历质量评分检查是提高病历质量的一种好办法。
In order to unify the medical records writing format and improve the quality of medical records, our hospital began in June 1982, pilot “clinical medical records quality inspection score ”. Through more than six months of practice, the hospital’s medical record quality significantly improved, received higher praise. In last year’s military health checkup organized by the Military Medical Affairs Department of the Military Command, our hospital scored first in the region. This year, the Military District Logistics and Health Department again put our hospital “clinical medic medical records quality inspection pilot grading standards ” as part of the division of the hospital medical quality inspection score standards and methods of one of the pilot program. In practice, we feel that medical records quality score examination is a good way to improve the quality of medical records.