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目的:加强病历档案的质量控制,以提升医院管理水平和医疗质量水平。方法:参照相关标准对我院2008年的所有出院病历进行质检。结果:缺陷病历主要体现在病人基本信息不全、主要诊断选择不正确、诊断不规范、住院病历书写不规范及其他各类缺项等。结论:通过强调病历档案质量的重要性,定期对病历进行考核以及加强终末质检,可以有效的提高病历档案的质量。
Objective: To strengthen the quality control of medical records in order to improve the level of hospital management and medical quality. Methods: With reference to relevant standards for quality inspection of all discharged medical records in our hospital in 2008. Results: The defects of medical records were mainly reflected in the basic information of patients is incomplete, the main diagnostic options are not correct, the diagnosis is not standardized, non-standardized hospital records and other types of missing medical records. CONCLUSIONS: By emphasizing the importance of the quality of medical records, regular examination of medical records and enhancement of final quality control can effectively improve the quality of medical records.