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目的以二级综合医院评审为契机,促进病案统计质量持续改进。方法解读2012年版二级医院综合医院评审标准,贯彻专项要求,狠抓落实核心条款,完善条款的支撑材料,加强部门协作性。结果提高了科室凝聚力,规范制度建设,加强病案人员及临床医师对国际疾病分类编码认识,达到核心条款A级水平。各项条款工作常态化,促进了管理的系统化建设。结论二级综合医院评审使病案统计管理规范化、常态化,实现病案统计工作质量持续改进。
The purpose of the second-level general hospital review as an opportunity to promote continuous improvement of the quality of medical records. Methods Interpretation of the 2012 version of the second-level hospital general hospital review standards, implementation of special requirements, pay close attention to the implementation of the core provisions, improve the support materials of the article, to strengthen departmental collaboration. The results improved department cohesion, standardize system construction, strengthen medical personnel and clinicians understanding of the international classification of diseases code, to the core provisions of the A level. Various provisions of the work of normalization, and promote the systematic management of the building. Conclusion The review of second-level general hospitals standardized and normalized the medical records management, and the continuous improvement of the quality of medical records statistics.