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病案是医疗信息的重要载体。本文介绍我院采取五项病案质量管理措施。一、做好病案服务工作:复印病历。二、抓病案形成环节质量:1科主任负责制。2举办病案书写岗前培训班。3抽查病房运行病历。三、严格管理病历书写事宜:有三种情况不能重新抄写病历记录。四、病历展览与病历奖惩:与奖金挂钩。五、终末质量控制与召开病案委员会:病案室每月上报医务处病案质量情况。定期召开病案委员会,解决新问题,保证医疗质量服务于广大人民群众。
The medical record is an important carrier of medical information. This article describes the five quality management measures taken by our hospital. First, do a good job in medical records: copy medical records. Second, grasp the quality of the disease to form a link: 1 department director responsible system. 2 Hold medical record written pre-job training classes. 3 check the ward running medical records. Third, strict management of medical record writing matters: There are three cases can not be re-transcribed medical records. Fourth, medical records exhibition and medical records rewards and punishments: linked with bonuses. V. Final quality control and medical record case: The case record office reports monthly the medical record quality of the medical department. The medical record committee is regularly held to solve new problems and ensure the quality of medical services to the general public.