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病案能体现医院几乎所有的核心制度,其质量水平是医院整体质量的缩影。而如何提高病案质量是困扰医院管理者的常见问题之一。本文从病案质量的影响因素着手,分析了质量意识、质控体系、领导重视程度和医务人员的业务素质对病案质量的影响;剖析了培训与这些影响因素的关系;结合具体的工作实践,阐述了如何提高培训效果,从而最终提高病历质量。
The medical record can reflect almost all the core systems of the hospital, and its quality level is a microcosm of the overall quality of the hospital. How to improve the quality of medical records is one of the common problems that plague hospital administrators. This article starts from the influencing factors of the quality of medical records, analyzes the impact of quality awareness, quality control system, leadership emphasis, and the quality of medical staff on the quality of medical records; analyzes the relationship between training and these influencing factors; and elaborates on the specific work practices. How to improve training results, and ultimately improve the quality of medical records.