摘要
病历质量是医疗质量的集中体现,高质量的病历来源于高标准、严要求。院领导的重视支持是做好此项工作的关键。在病历质量管理上,要不断完善制度,加强学习培训,明确职责,加强督察,设计载体,严格奖惩标准,定期考核公示。以病志的内涵质量检查为重点,在检查中发现医疗质量问题,及时整改,使医疗制度完善并落实到位,从而提高医疗质量,保证医疗安全。以病历质量为抓手,是提高医疗质量、保障医疗安全的有效途径。
The quality of medical records is the centralized reflection of medical quality. Medical records of high quality lie in high standards and strict requirements. The attention and support of the hospital leaders is the key in doing the work well We should constantly improve system, strengthen study and training, clarify responsibilities, enhance super- vision, design carder, adhere strictly to the standards of reward and penalty, publicize the results of examinations periodi- cally, focus on the quality examination on the connotation of medical records, find out problems of medical quality, timely rectify them, perfect medical system and make concrete implementation so as to improve medical quality and ensure med- ical safety. Starting from the quality of medical records is the effective route to upgrading medical quality and ensuring medical safety.
出处
《现代医院管理》
2009年第4期33-34,共2页
Modern Hospital Management
关键词
病历
质量管理
medical record
quality management
