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目的病历的终末质量监控、病历评级打分自20世纪80年代以来已经进行了20余年,主要为提高医务人员的病历书写质量,此举曾推动了各级领导和医务人员对病历书写的重视,病历书写质量得到一定的提高。然而在漫长的岁月中病历书写的内在质量并没有得到更多的改善,一些单位对病历的评价实质是流于对病案书写格式的评定,人为的提高病案的甲级率,对病历内涵质量的监控力度不够,修改病历的行为没有减弱。真实完整地写好病历记录乃是医师的天职,甲级病历应是医师们尽职尽责书写完成的,不能为了医院达标上等提高评分。医疗事故处理条例颁布以来,许多医疗纠纷都对病历书写纠缠不清,甚至某一疏漏遭致败诉。结果临床医师要加强自律,身体力行写好病历,严格执行三级医师查房制,作好病历书写的环节质量控制,促进医疗质量和病历书写质量的提高,确保医疗安全。
The final quality control of the medical record of the target medical record and the rating of medical records have been scored for more than 20 years since the 1980s, mainly to improve the medical record writing quality of medical personnel. This has promoted the attention of medical leaders at all levels to medical record writing. The quality of medical records has been improved. However, in the long years, the intrinsic quality of medical records has not been further improved. Some organizations’ evaluation of medical records is in essence concerning the assessment of the written format of medical records, artificially improving the grade A rate of medical records, and the quality of medical records. Monitoring is not enough, and the behavior of modifying the medical records has not weakened. It is the duty of the physician to write the medical record in a true and complete manner. The grade A medical record should be written and completed by the doctors due diligence. Since the promulgation of the Medical Accident Handling Regulations, many medical disputes have been tangled in the medical records, and even a certain omission has been lost. As a result, clinicians should strengthen self-discipline, practice good medical records, strictly implement the third-level doctors’ house-checking system, make quality control of medical record writing, promote the improvement of medical quality and medical record writing quality, and ensure medical safety.