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目的强调病历书写质量反映了对医疗质量水平的认识,对病历内涵质量的监控、考核的实质就是对医疗质量的监控考核;加强病历环节质量控制,促进医疗质量和病历书写质量的提高。结果各级各类医师加强法律法规的学习,提高了自我保护意识,自主管理,严格执行医疗核心制度,发挥四级质控网络作用,依法行医,自律行事,写好病历,管好病历,用好病历,防范医患纠纷,确保医疗安全,病历内涵质量明显提高。
The purpose of emphasizing the quality of medical records reflects the level of medical quality awareness, the quality of medical records monitoring, the essence of assessment is to monitor the quality of medical assessment; to strengthen the quality control of medical records to promote the quality of medical care and medical records to improve the quality of writing. Results All kinds of physicians at all levels strengthened the study of laws and regulations, improved their awareness of self-protection and self-management, strictly implemented the medical core system, played a role of quality control network of four levels, practiced medicine according to law and performed their own actions, wrote medical records, Good medical records, prevent disputes between doctors and patients to ensure medical safety, significantly improve the quality of medical records.