摘要
病案从侧面反映医院医疗质量好坏、医疗技术高低,是医疗事件中最为重要的法律证据,质量把关尤为重要。我院制定了一套量化、细化的终末病案质控体系,包括实施办法、质量检查表、分值对照及评审标准。在实施后各临床科室高度重视,各种严重缺陷率与重点项目差欠情况明显好转,体系运行效果非常明显,有较大的推广价值。
Medical records reflect medical quality and medical techniques of a hospital and they act as the significant legal evidence in medical accidents so quality control is extremely important.A set of quality control system for quantified and refined medical records at the end of hospitalization was made in our hospital,including the implementing methods,the table of quality examination,scores for checking and the evaluation standard.During the implementation,each clinical department paid high attention,grave defects and worse situation of each key project was improved obviously.The system works quite well and deserves great promotional value.
出处
《现代医院管理》
2011年第5期40-43,共4页
Modern Hospital Management
关键词
住院病案
终末病案
质量控制体系
医疗质量管理
medical record of termination
quality control system
medical quality management
