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目的针对病案首页填写缺陷,制定质量监控和改进措施。方法通过质量控制检查部门的检查修改和定期反馈检查,分析首页缺陷原因,提出改进措施并跟踪改进效果。结果病案首页缺陷明显减少,无缺陷病案首页从零提高到39.3%。结论提高病案首页填写质量,必须持之以恒地加强病案质量管理,必须增强医护人员的责任心,提高临床医师的业务素质。
Objective To fill in the first page of the medical record and establish quality control and improvement measures. Methods Through the inspection and revision of quality control inspection department and regular feedback inspection, the paper analyzed the causes of home defects, put forward the improvement measures and tracked the improvement effect. Results of the first page of medical records significantly reduced the number of defects-free medical records increased from zero to 39.3%. Conclusion To improve the quality of medical records homepage, we must persevere in the quality management of medical records, we must enhance the sense of responsibility of medical staff and improve the professional quality of clinicians.