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本文简要阐述了在新形势下提高病案内涵质量的重要性。从病案记录的诊断、治疗上罗列了病案内涵质量缺陷的一些表现形式。如何预防这些缺陷的发生?提出提高病案内涵质量的几点建议,即:强化临床各级医师的质量、法律、责任三个意识;提高医师自身素养;从抓医疗质量入手,保证三级医师查房;落实质控医师职责;重视监控与反馈的作用。这些既是医疗质量的基础,也是产生优质病案的前提。这需要含辛茹苦渐进的过程,“润物细无声”的辛勤耕耘,不能企望一蹴而就,更不是为了应付检查临时抱佛脚所得到的。
This article briefly explains the importance of improving the connotation and quality of medical records in the new situation. From the diagnosis and treatment of medical records, some of the manifestations of the quality defects of medical records are listed. How to prevent the occurrence of these defects? Put forward some suggestions to improve the connotation and quality of medical records, namely: to strengthen the three levels of consciousness of clinical doctors at all levels of quality, law, and responsibility; to improve the quality of physicians themselves; from the start to grasp the quality of medical care to ensure that the three doctors check Housing; implement quality control physician duties; attach importance to the role of monitoring and feedback. These are the foundation of quality of care and are also prerequisites for generating quality medical records. This requires a process of gradual progress, and the hard work of “creating something without sound” cannot be expected to be carried out overnight, not to cope with the temporary cuddle.