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目的总结我院病案质量管理方法,以提高病案质量。方法加强培训,提高认识;建立三级质控网;完善病历质量管理制度;注重运行环节质量控制;实施奖惩结合措施。结果病历质量甲级率从2000年85%提高到2006年的95%以上。结论三级质控网的建立,制度化、规范化的管理,奖惩措施的实施是提高病历质量的重要举措。
Objective To summarize the quality management methods of medical records in our hospital in order to improve the quality of medical records. Methods To strengthen training and raise awareness; establish a three-level quality control network; improve the medical record quality management system; focus on the quality control of the operation link; Results The grade A quality of medical records has increased from 85% in 2000 to over 95% in 2006. Conclusion The establishment of three-level quality control network, institutionalized and standardized management, and the implementation of incentive and punishment measures are important measures to improve the quality of medical records.