论文部分内容阅读
目的随着人们对健康和法律意识不断增强,对住院病历真实性、完整性、科学性提出了更高的要求。为加强我院病案质量管理,规范病历的书写,提高电子病案质量,防范医疗纠纷,对网络环境下病案全程进行基础、环节、终末质量进行监控与规范。方法病人入院后规范各级医师病历书写标准,严格按照2002年9月国家卫生部颁布的《病历书写基本规范(试行)》实施,提高医务人员业务素质。结果医师严格把关,规范疾病诊断和手术操作名称。结论通过对病历质量全程监控与规范,提高全院病案质量。
Objectives As people’s health and legal awareness continue to increase, higher requirements are placed on the authenticity, completeness, and scientificity of inpatient records. In order to strengthen the quality management of medical records in our hospital, standardize the writing of medical records, improve the quality of electronic medical records, and prevent medical disputes, we will monitor and standardize the basic, link, and final quality of the medical records under the network environment. Methods After the patient was admitted to the hospital, he standardized the medical record writing standards for doctors at all levels, and strictly followed the “Basic Rules for Writing Medical Records (Trial)” promulgated by the Ministry of Health in September 2002 to improve the professional quality of medical personnel. As a result, doctors strictly controlled and standardized the name of the disease diagnosis and operation. Conclusion By monitoring and standardizing the quality of patient records, the quality of medical records in the hospital is improved.