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目的加强医疗质量控制,探讨病历书写质量和管理的改进方法。方法以中医医院运行病历的质控为切入点,明确环节质控的主要内容,剖析病历书写中存在的主要问题。结果提出依法质控,必须加强对运行病历的实时监控。结论完善以病区质量监控为基础、环节质量监控为重点的过程监控方式的质控模式,落实病历书写的客观性、真实性、及时性和完整性,对提高病历质量、防范医疗纠纷起到了积极作用。
Objective To strengthen medical quality control and explore ways to improve the quality and management of medical records. Methods Starting with the quality control of medical records in Chinese medicine hospitals, the main contents of quality control of the links were clarified and the main problems in the writing of medical records were analyzed. The results suggest that quality control according to law, we must strengthen the running of medical records in real time monitoring. Conclusion The quality control mode of process monitoring, which is based on ward quality control and link quality monitoring, is consummated. The objectivity, authenticity, timeliness and integrity of medical record writing are fulfilled, and the quality of medical records is improved and medical disputes are prevented positive effects.