论文部分内容阅读
目的通过剖析传统病案质控的局限性,介绍如何构建分级精细化质控体系及其科学性。方法分解卫生部《病历书写基本规范》评分标准,制作成四个级别的质控标准对病案进行分级质控,分层面找出各级的缺陷重点,有针对性进行突破。结果以卫生部的《病历书写基本规范》)作终末质控,评价结果缺少针对性;而采用分级精细化标准评价,可分级判别病案具体缺陷。结论分级精细化病案质量监控从完整性、内涵性、专项性、医学逻辑性四个方面更加深入,可以找出病案具体缺陷,有针对性地给予临床医生建议。
OBJECTIVE: To describe how to construct a grading quality control system and its scientific nature by analyzing the limitations of traditional case quality control. Methods Decompose the score of “basic norms of medical record writing” issued by the Ministry of Health, and make quality control standards of four levels to grade and control the medical record, find the key points of defects at all levels and make breakthroughs targetedly. The results of the Ministry of Health “basic medical records writing” as the final quality control, the lack of relevance of the evaluation results; and the use of grading standard evaluation can be classified to determine the specific defects of medical records. Conclusion The grading of the quality of medical record case monitoring is more thorough from four aspects: integrity, connotation, specialization and medical logic, so we can find out the specific defects of the medical record and give the advice to clinicians pertinently.