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病案质量是医疗质量管理的重点,提高病案质量,加强病案质量管理至关重要。我院与省内其他三甲医院开展病案互评活动以来,医院间取长补短,取得了较好的质控效果,在病案首页信息完整、出院记录出院医嘱详细、病程拷贝、上级医师查房内涵、不正确修改病案等方面均有较大改善,病案质量得到全面提升。同时,病案互评活动还提高了互评医院质控人员的病案质控水平,充分调动了临床医师自我病案质控,书写高质量、高标准病案的积极性,主动性。病案互评为病案质控提供了新的模式,是医院内病案质控的有力补充。通过病案互评程序的不断完善,使病案互评模式得到持续改进。
Quality of medical records is the focus of medical quality management, improve the quality of medical records, medical records to strengthen quality management is essential. Since our hospital and other top three hospitals across the province have conducted mutual medical examination and evaluation activities, the hospital has achieved good results in quality control. The information on the front page of the medical record is complete, and the details of the discharge order, the copy of the course, Correctly modify the medical records and other aspects have greatly improved the quality of medical records have been fully improved. At the same time, the mutual assessment of medical records also raised the quality control of medical staff in CRBT hospitals, which fully mobilized the enthusiasm and initiative of clinicians in self-record quality control and writing of high-quality and high-standard medical records. The mutual recognition of medical records provides a new model for the control of medical records and is a powerful supplement to the quality control of medical records in hospitals. Through the continual improvement of the procedures for mutual assessment of medical records, the pattern of mutual assessment of medical records has been continuously improved.