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目的为了提高病案质量水平,探讨我院现阶段病案质量存在问题,提出改进措施。方法参照《广东省病案书写规范》,从日常病案质控工作中总结分析病案质量存在问题。结果病案质量存在多方面问题。结论要制定健全的病案质量监控制度,落实严格有效的管理措施,以提高病案质量。
Objective To improve the quality of medical records, to discuss the existing problems of medical records in our hospital at this stage, and to propose improvement measures. Methods With reference to the “Guangdong province medical record writing norms”, from the daily medical record quality control work to summarize and analyze the medical record quality problems. Results There are many aspects of the quality of medical records. Conclusion To establish a sound system for the quality of medical records, the implementation of strict and effective management measures to improve the quality of medical records.