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目的通过对终末病历质量评价的系统化管理,及时反馈终末病历评价信息。方法使用信息系统对终末病历质量进行评价管理。结果对终末病历评分标准,评级准确。结论有效纠正临床医生病历书写中的缺陷,可提升病历文书书写质量,减少医疗纠纷。
OBJECTIVE Through the systematic management of the quality evaluation of the final medical records, feedback information of the final medical records is fed back in time. Methods The information system was used to evaluate the quality of the final medical record. The results of the final medical record scoring criteria, accurate rating. Conclusion The effective correction of the defects in the writing of medical records by clinicians can improve the writing quality of medical records and reduce the medical disputes.