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目的了解临床各科影响病历书写质量的主要因素及质量控制在病历书写过程中的重要作用。方法按照江西省《住院病历质量评价标准(试行)》对归档病案评价、统计、分析。结果质控后平均每份病案缺陷数及病案缺陷率较质控前显著提高。结论提高病案质量要充分发挥各级质控组织的职能作用,同时临床医师要增强工作责任心。
Objective To understand the main factors influencing the writing quality of clinical records and the important role of quality control in the writing of medical records. Methods According to Jiangxi Province “inpatient medical records quality evaluation criteria (Trial)” on the file medical records evaluation, statistics and analysis. Results After the quality control, the average defect number per case and the defect rate were significantly higher than those before the control. Conclusion To improve the quality of medical records, it is necessary to give full play to the functions and functions of quality control organizations at all levels. At the same time clinicians should enhance their sense of responsibility.