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根据前卫生部《病历书写基本规范》和《医疗机构病历管理规定》的要求,病案内涵质量的关键是真实性、基础是准确性、保障是及时性。提高病案内涵质量的方法从健全科室监督、完善考评制度、加强环节质控、定期法律培训入手,提高病案内涵质量的根本在于临床医师,最大限度的挖掘各级医师的管理职能。病案内涵质量的改善需要终末质量监控人员内外联合,最终实现医务人员法律与服务意识的整体提升。
According to the former Ministry of Health “Basic Medical Records Writing Regulations” and “medical institutions medical records management requirements,” the key to the quality of medical records content is authentic, based on accuracy, protection is timely. Methods to improve the quality of medical records from the sound department supervision, improve the evaluation system, to strengthen quality control, regular legal training to start, improve the quality of medical records of the essence lies in the clinician, to maximize the management of mining physicians at all levels. The improvement of the quality of the medical records needs the combination of internal and external terminal quality control personnel to ultimately achieve an overall improvement in the legal awareness and service awareness of medical personnel.