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通过对某地市级三甲医院医务人员进行问卷调查,了解医务人员对病案质量控制的认识和态度,从医务人员的角度分析病案质量存在缺陷的原因和对策。发现部分医务人员缺乏法律和质量意识,不了解病案质量控制的方法和过程,自身业务能力和素质的缺陷等是病案质量缺陷的主要原因。提出加强培训和教育,提高医务人员的法律意识和质量意识,提高医务人员的业务能力和综合素质;建立奖惩制度,强调三级医师负责制;实行人性化管理等对策以提高病案书写质量。
Through the questionnaire survey of the medical staffs of the top-level hospitals in a certain city, we can understand the medical staffs’ cognition and attitudes toward the quality control of the medical records and analyze the reasons and solutions of the defects in the quality of the medical records from the perspective of the medical staffs. It is found that some medical staffs lack the awareness of law and quality, and they do not understand the methods and processes of quality control of medical records, and the defects of their professional ability and quality are the main reasons for the quality defects of medical records. It is proposed to strengthen training and education, raise legal awareness and quality awareness of medical staff, and improve the professional ability and overall quality of medical staff; establish reward and punishment system, emphasize the responsibility system of three-level physicians; and implement humanized management measures to improve the quality of medical record writing.