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目的分析和审核出院病案中存在问题,使病案管理更加完善。方法加强出院病案的管理,各临床科室审核员认真审核出院病案,合格后办理出院手续。并记录所存在的问题,及时与有关人员沟通和反馈,规范各级医务人员的日常行为。结果出院病案合格率由76.6%上升至97.9%。结论审核员严格审核出院病案,把差错消灭在萌芽状态,从源头上杜绝病案质量缺陷,规范各级医务人员行为,使病案管理更加完善。
Objective To analyze and examine the existing problems in the discharged medical records and make the medical records management more perfect. Methods to strengthen the management of discharged cases, all clinical departments auditors carefully examine and discharge cases, qualified for discharge procedures. And record the existing problems, timely communication and feedback with relevant personnel, standardize the daily behavior of medical staff at all levels. Results The qualified rate of discharged medical records increased from 76.6% to 97.9%. Conclusions The auditors strictly examine the discharged medical records and eliminate the errors in the bud, eliminate the defects of the medical records at source, and standardize the behaviors of the medical staff at all levels so as to make the medical records management more perfect.