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通过医疗纠纷病案的有效内部审核,评价诊疗过程的符合性和有效性。对医疗纠纷病案采取诊疗过程的正向审核方法,对其诊疗过程的审核重点在于落实核心制度的基础上对问诊、查体过程、辅助检查过程、治疗方案符合性及治疗方案的实施、调整和更改而需要采取的措施等项目的审核。为院方采取有效纠正和预防措施,避免医疗纠纷的发生提供依据,对提高病案质量具有重要的现实作用。
Evaluate the compliance and effectiveness of the treatment process through an effective internal audit of medical disputes. The medical examination and treatment of medical disputes during the positive review of the audit process, the review of its treatment process focuses on the implementation of the core system on the basis of the inquiry, physical examination process, auxiliary examination process, the compliance of treatment programs and treatment programs, adjust And changes need to take measures such as the project audit. For the hospital to take effective corrective and preventive measures to avoid the occurrence of medical disputes provide the basis for improving the quality of medical records has an important practical role.