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目的了解我院病案管理现状,寻求质量管理的方法,提高质量。方法利用分级质控[1]方法对我院的运行病历和出院病案进行质量分析。结果根据医院“等级评审标准”要求查找不足,针对部分病历存在的书写、管理的质量缺陷,制定并实施相应的“奖惩”制度。结论病案质量管理是医院质量管理的一个重要组成部分,它是评价医疗质量、评审医院管理水平的可靠依据。
Objective To understand the current situation of medical record management in our hospital, seek ways of quality management and improve quality. Methods The grading quality control [1] method was used to analyze the running records and discharged cases in our hospital. Results According to the hospital “level assessment criteria ” requirements to find inadequate, for some medical records exist, the quality of management defects, the development and implementation of the corresponding “reward and punishment” system. Conclusion Medical records quality management is an important part of hospital quality management. It is a reliable basis for evaluating the quality of medical services and evaluating the management level of the hospital.