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目的通过卫生监管规范病历书写,协助医疗机构提升医疗质量。方法选取辖区内四家二级以上综合性医疗机构,对医务人员进行多层次法律法规培训,对运行病历进行监督检查,对检查中存在的缺陷及时向医疗机构反馈并要求其整改。结果病历书写中总体缺陷情况较前有所改善,但仍有部分缺陷情况存在反复。结论病案质量的提高除了需要医疗机构加强自身管理外,卫生监督部门的有效监管也至关重要。
Objective To standardize the medical records through health supervision to help medical institutions improve the quality of medical care. Methods Four comprehensive medical institutions within the jurisdiction were selected to conduct multi-level legal and regulatory training on medical staff, to supervise and inspect medical records, and to promptly report the medical defects and request rectification. Results The overall defects in medical record writing were improved compared with the previous period, but there were still some defects that were repeated. Conclusion In addition to the need to improve the quality of medical records in medical institutions to strengthen their own management, the effective supervision of health oversight departments is also crucial.