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目的探讨提高病案质量的新措施。方法随机抽取我院2010年7月-2010年10月间的出院病案3000份进行质控分析。结果甲级病案2872份(95.73%),乙级病案128份(4.27%),无丙级病案;病案缺陷共5430处,其中临床基础与规范类缺陷占55.49%、医疗安全记录类缺陷占28.71%、诊疗技术与用药类缺陷占15.80%。结论通过对临床医师进行法制和专业知识培训,以提高病案书写能力;利用医院信息管理系统,对病案质量进行实时监控是一种新的病案管理模式;建议进一步完善药物使用等管理制度,确保病历内涵质量的提高;应结合《侵权责任法》进一步规范临床医师诊疗行为。
Objective To explore new measures to improve the quality of medical records. Methods We randomly selected 3000 hospitalized cases from July 2010 to October 2010 in our hospital for quality control analysis. Results There were 2872 Grade A cases (95.73%) and 128 (4.27%) Grade B cases without Grade C cases. There were 5430 cases with defect in clinical records, accounting for 55.49% of the total cases, and 28.71 cases of medical safety records %, Diagnosis and treatment of technical defects and medication accounted for 15.80%. Conclusion It is a new case management mode to use the hospital information management system to monitor the quality of medical records in real time through the legal and professional knowledge training of clinicians to improve the medical record writing ability. It is suggested to further improve the management system of drug use and ensure the medical record The quality of connotation should be improved; clinicians should be further standardized in their practice of tort liability.