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目的探求保持病历质量持久发展的质控管理方法。方法对照《广东省病历书写规范》,回顾性调查6年出院病历质控结果、质控管理上出现的问题、针对问题采取的措施、改进后的效果,总结提高病历质量的可行方法。结果病历质量整体呈上升趋势;质控后病历甲级率增高,丙级病历消除;病历质控管理实践中不断有管理困难出现;适时修正问题、持续改进工作方法能提高质历质量。结论健全质控组织体系、合理调整不适宜的评价指标体系、建立有效的反馈和交流机制、渗入人性化管理思潮是提高病历质量的有效途径。
Objective To explore a quality control management method to maintain the sustainable development of medical record quality. Methods According to the “Medical Records Writing Standard of Guangdong Province”, the retrospective investigation was made on the quality control results of six-year discharge records, quality control and management problems, the measures taken for the problems and the improved results, and the feasible ways to improve the quality of medical records were summarized. Results The overall quality of the medical records showed an upward trend. After the quality control, the Grade A medical records were increased and the medical records of Grade C were eliminated. Management difficulties occurred in the quality control management of medical records. Problems were corrected timely and continuous improvement of working methods could improve the quality of the historical records. Conclusion It is an effective way to improve the quality control organization system, reasonably adjust unsuitable evaluation index system, establish effective feedback and exchange mechanism and infiltrate the thought of humanized management.