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20世纪90年代初随着医院等级评审的开展众多医院出现了病案书写质量管理专职人员为纠正和保证病案质量设立了岗位,并延续至今。医院管理者看到了病案质量中存在着不足,其中的缺陷是引起医疗纠纷的最主要原因之一,更为重要的是病案记录的信息直接表达医院管理的状态和技术水平,而医院等级评审中大量指标来自病案。但病案质量中的严重缺陷已开始影响医院的正常经营。必须采取某种方式进行有效地管理,故尔非人事正式编制序列中产生的病案质量控制的工作岗位。在我院10余年的实践中逐步感到这种终末管理方式虽有效,但十分有限。这种管理模式产生的误区也为医院和临床带来了误解和不良依赖性,提出供同道讨论。
In the early 1990s, with the advent of hospital-level accreditation, many hospitals appeared to set up posts for the correction and assurance of the quality of their medical records. Hospital administrators have seen the quality of the medical records there are deficiencies, the defects of which is one of the most important causes of medical disputes. More importantly, the information of medical records directly expresses the status and technical level of hospital management. However, A large number of indicators from the medical record. However, serious defects in the quality of medical records have begun to affect the normal operation of the hospital. There must be some way for effective management of the positions in quality control records generated in the non-personnel formal compilation sequence. In our hospital more than 10 years of practice gradually felt that although this terminal management is effective, it is very limited. Misunderstandings arising from this management model have also brought misunderstandings and bad reliance to hospitals and clinics and proposed discussions for fellow citizens.