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目的通过规范社区卫生服务中心病历书写,提高医疗质量,保障医疗安全。方法成立本社区卫生服务中心病历管理领导工作小组,按照卫生部颁发的《病历书写基本规范》和上海市卫生局对病历书写的相关要求,制定本中心病历书写细则,并从环节入手,实行动态管理。结果门诊病历、住院病历及家庭病床病历得到规范,环节质量、内涵质量均有较大提高,减少了医疗纠纷及医疗事故的发生。结论制定社区卫生服务中心病历书写细则,实施动态管理,有利于提高医疗质量,减少医疗纠纷,保障医疗安全。
Objective To improve the medical quality and ensure the medical safety by standardizing the writing of medical records of community health service centers. Methods The leading group of medical records management of this community health service center was set up. According to the Basic Medical Record Writing Standards issued by the Ministry of Health and the relevant requirements of the Shanghai Municipal Health Bureau for writing medical records, the detailed rules for the writing of the medical records of the center were formulated. management. Results Outpatient medical records, hospital records and family beds medical records were standardized, the link quality, quality of content have greatly increased, reducing the medical disputes and medical malpractice. Conclusion The development of community health service center medical records writing rules, the implementation of dynamic management, help to improve the quality of medical treatment, reduce medical disputes and ensure medical safety.