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为了适应医院质量管理整体监控的需要,天津市卫生局成立了十二个质量控制中心。其中病案质控中心做为对全市病案质量管理的监督控制系统,在病案质控力度加强的同时,病案管理也进一步发展到科学化、规范化管理,病案质量明显提高。全市二级医院病案甲级率从85％提高到93％,三级医院达到96％以上。本文着重介绍了病案质控中心的性质、任务和工作方法,总结了病案质控中心成立以来的工作经验与体会。指出了影响病案质量的因素,同时提出了今后的工作方向与设想。
In order to meet the needs of the overall monitoring of hospital quality management, the Tianjin Municipal Health Bureau established twelve quality control centers. The Quality Control Center for Diseases as a supervisory and control system for the quality management of medical records in the city, while the quality control of the medical records has been strengthened, the medical record management has further developed to scientific and standardized management, and the quality of medical records has been significantly improved. The Grade A medical grade rate of secondary hospitals in the city has risen from 85% to 93%, and tertiary hospitals have reached 96% or more. This article focuses on the nature, tasks and working methods of the case quality control center, and summarizes the work experience and experience since the establishment of the case quality control center. Pointed out the factors that affect the quality of medical records, and at the same time put forward the direction and ideas for future work.