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目的提高病案质控效能,确保病案质量。方法通过病案全程质控找出存在的问题,分析产生的原因,制定改进措施。结果质控方法存在表面化、形式化、职责不清、奖惩不利、行政误导等,应采取全程性病案质控机制。结论病案质控管理中,由终末质控为环节质控,抓好全员质量教育,树立法制观念,实施责、权、利明确的质控逐级负责制,认真落实病案质控措施。
Objective To improve the quality of medical record control and ensure the medical record quality. Methods Through the quality control of medical records to find out the existing problems, analyze the causes and make improvement measures. Results quality control methods exist in the surface, formal, unclear responsibilities, rewards and penalties adverse, misleading, etc., should take full control of the quality of the case record. Conclusion In the quality control management of medical record, the quality control of end-of-life is the quality control step by step. The quality education of all staff should be grasped, and the concept of legal system should be established. The responsibility system of responsibility, power and profit should be implemented step by step.