论文部分内容阅读
目的规范病案首页填写内容,确保医院病案信息的真实、准确。方法对病案首页信息填写常见缺陷进行评析。结果病案室质控医师对终末病历进行逐份评估,病案录入人员在录入时检查首页填写情况,定期将检查结果进行统计、总结,及时将结果反馈于各临床科室,由医务处负责督促改正。结论通过长期对病案首页质量的检查-反馈-督促改正,在全院树立全面(全院、全员、全过程)质量管理意识,提高病历书写质量,使病案首页填写内容准确、完善,确保统计数据的真实性、准确性,提高医疗质量。
Objective To standardize the first page of the medical record to ensure that the medical record of the hospital is truthful and accurate. Methods To comment on the common defects in the first page of medical records. Results The case-control physicians performed an end-to-end assessment on the final medical records. The medical records entry personnel checked the first page of the medical records at the time of entry. The results were regularly collected and summarized. The results were fed back to clinical departments in time. . Conclusion Through the long-term inspection of the quality of the first page of medical records - feedback - supervision and correction, establish a comprehensive (whole hospital, full, whole process) quality management awareness in the hospital to improve the quality of medical records writing, the first page of medical records to complete the content accurate and perfect to ensure that statistics Data authenticity, accuracy, improve medical quality.