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一份高质量的病案质量简报不仅能够反映出一个医疗机构的诊疗水平、管理水平,也体现出病案室工作人员认真的工作态度。本文就某院病案室结合实际工作需求,设计完成《病案质量简报》的基本框架及内容。医院病案室采用统计图表加文字分析的形式设计《病案质量简报》,内容主要包括医院收治情况、病案编目情况、病案质控情况、病案流通情况等四大部分的图表信息,以及穿插其间的各类报表分析、工作情况、问题通报、经验教训等。其主要目的是实现对病案内容进行更深层次的挖掘后,以最直观、最易被接受的方式呈现在医院各级工作人员面前,并提出可靠的建议以供参考,使病案的作用得到最大的发挥。
A high-quality medical record quality briefing not only reflects the level of medical treatment and management of a medical institution, management level, but also reflects the staff’s serious working attitude. This article combines the actual work requirements of a hospital case, designed to complete the basic framework and content of “medical record quality briefing.” The hospital medical record room adopts the form of statistical charts plus text analysis to design the “medical record quality briefing”, which mainly includes the chart information of the four major parts such as hospital admission, case record, medical record quality control and medical record circulation, Class report analysis, work conditions, problem notification, experience and lessons. Its main purpose is to realize the deeper excavation of the medical record content and present it in the most intuitive and easily accepted way to all levels of staff in the hospital and make credible suggestions for reference so as to maximize the effect of the medical record Play