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目的通过对400份临床路径管理的病案质量分析,探索提高临床路径管理病历书写质量的办法。方法根据临床路径工作内容和病历书写规范要求,提出了医院临床路径管理病历书写质量监控标准,对400例临床路径管理的病案进行质量分析。结论利用医院病案质量管理网络加强临床路径实施过程中病案环节质量和终末质量监控,促进病案质量提高。根据临床路径工作内容、流程,制定统一的临床路径管理病历书写质量考评标准,有利于病案质量的监控。
Objective To explore the ways to improve the writing quality of clinical path management medical records through the analysis of medical record quality of 400 clinical path management. Methods According to the work content of clinical pathway and medical record writing standard, the paper put forward the monitoring standard of clinical path management medical record writing quality in hospitals and analyzed the quality of medical records of 400 clinical path management cases. Conclusion The use of hospital medical records quality management network to strengthen the clinical path of the implementation of the medical record quality and final quality control, improve the quality of medical records. According to clinical path work content, process, develop a unified clinical path management record writing evaluation standards conducive to the quality of medical record monitoring.