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目的针对病案中存在的缺陷,采用持续质量改进的管理方法,进一步提高病历书写质量。方法对整改前后的2007年1月和2007年10月的出院病案存在的缺陷分别进行统计、分析。结果实施整改措施后,病历书写质量明显提高。结论加强病历形成环节中的质量监控是提高病案内涵质量的关键。
Objective To improve the quality of medical record writing by adopting the management method of continuous quality improvement in view of the defects existing in the medical record. Methods Before and after the rectification of January 2007 and October 2007 discharge cases were analyzed for the shortcomings. Results After the rectification measures were implemented, the quality of medical records was significantly improved. Conclusion Strengthening the quality control in the formation of medical record is the key to improve the quality of medical records.