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目的探讨病历质量管理体系的构建对提高病历质量,规范医疗行为,保证医疗安全的影响。方法随机抽取2009年1月至2013年12月间在院运行病历和出院归档病案的质控检查记录各500份,比较病历质量管理体系实施前后住院病历在完成及时性、书写规范性和等级评定结果存在的差异。结果通过病历质量管理体系的构建与实施,病历书写及时率逐年提高,从68%增加到99%;运行病历及出院归档病案书写缺陷率逐年降低,从64%下降到5%;甲级病历率逐年提高,从67.5%提高到99.5%。结论构建病历质量管理体系,充分发挥各级病历质量管理组织的监管作用,增强医务人员规范书写病历的能力和自觉性,是提高病历质量的有效途径。
Objective To explore the construction of medical records quality management system to improve the quality of medical records, standardize medical behaviors and ensure the impact of medical safety. Methods A total of 500 QC records were recorded from January 2009 to December 2013 in hospital. The records of hospitalized patients before and after the implementation of the medical records quality management system were compared in terms of completeness of timeliness, standardization of writing and grading Differences in the results. Results Through the construction and implementation of the medical record quality management system, the medical record writing rate increased from 68% to 99% year by year. The defect rate of medical records and discharge records decreased from 64% to 5% year after year. Grade A medical records Increased year by year, from 67.5% to 99.5%. Conclusion It is an effective way to improve the quality of medical records by establishing the medical record quality management system, giving full play to the regulatory role of medical records quality management organizations at all levels, and enhancing the ability and consciousness of medical personnel to regulate the writing of medical records.