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医疗质量指标通过军字一号系统各个环节,特别是病案首页数据库,提取数据并生成各项医疗质量指标。近些年,军内外各医院都建立了病案质量控制体系,对提高病案质量起到了积极的促进作用,但其病案质量控制仍不同程度地存在着表面化、形式化、弄虚作假等问题。 从改进、完善病案质控、充分发挥病案质控作用目的出发,结合我院当前病案质量问题,谈点个人看法。
The medical quality indicators were extracted from all links of the Military Character One system, especially the database of medical records, and data were generated to generate various medical quality indicators. In recent years, all hospitals inside and outside the military have established a quality control system for medical records, which has played a positive role in promoting the quality of medical records. However, the quality control of medical records still has problems such as superficiality, formalization, and fraud. From the perspective of improving and perfecting the quality control of medical records and giving full play to the role of the quality control of medical records, we will discuss individual opinions based on the current quality of medical records in our hospital.