摘要
目的加强围手术期病历质量管理,提高病历内涵质量。方法制定围手术期病历质量监控表,对终末手术病案质量进行监控。结果核心制度执行不利,术前风险评估不到位,预防性使用抗生素级别偏高、时间偏长。结论应进一步加强医师业务素质的训练,加强抗生素的使用管理,推进临床路径的开展,以提高围手术期病历质量,保障医疗安全。
Objective To strengthen the quality management of perioperative medical record and to improve their connotation.Methods To work out quality form of perioperative medical record for monitoring final operation medical record quality.Results Unfavorable implement of core system;unfulfillment perioperative risk assessment;high level and long time of antibiotics using.Conclusion This article suggests that should further strengthen doctor professional qualities training and management of antibiotics using,push on the development of clinical pathway for improveing quality of perioperative medical record and ensuring medical safety.
出处
《中国病案》
2011年第3期14-14,13,共2页
Chinese Medical Record
