病案作为载体,是疾病诊治的全程记录。病案体现了一所医院的医疗质量,科技水平和经营管理的能力。抓好病案质量是提高医务人员业务素质的基本途径和加强医疗质量控制的重要环节,也是医院现代化建设的重要内容。随着医院改革的深化和医学科技的发展,医院经营和管理模式、诊疗和服务模式迅速变化。病案质量管理必须适应这个变化,适应医疗改革和医院发展的需要。我院的成功经验是病案质量的五个环节管理。 一、第一环节:医务科在全院组织以《江苏省病历书写规范》(第三版)为标准,在全院医务人员中开展了“五个三”教育活动。“五个三”即:病人做到 The medical record as a carrier is the full record of disease diagnosis and treatment. The medical record reflects the hospital’s medical quality, technological level, and management and management capabilities. Grasping the quality of medical records is a basic way to improve the professional quality of medical personnel and an important link in strengthening medical quality control. It is also an important part of hospital modernization. With the deepening of hospital reform and the development of medical science and technology, hospital management and management models, diagnosis and treatment and service models are rapidly changing. The quality management of medical records must adapt to this change and adapt to the needs of medical reform and hospital development. The successful experience of our hospital is the management of the five links in the quality of medical records. First, the first link: The Medical Department organized the “Five Thirds” education activities in the hospital’s medical staff in accordance with the “Jiangsu Provincial Medical Record Writing Standards” (third edition) as the standard. “Five-three” means: The patient will do