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病案不仅是患者医疗全过程的客观记录,也是具有法律效力的医疗文件。病案质量直接反映医院的医疗质量,是医院质量控制的重要内容。通过对953份内科系统出院病案进行终末质量控制的结果进行分析,阐述影响病案质量的因素和提高病案质量的相应措施,强调病案质量控制的重要性。
Medical record is not only an objective record of the patient’s medical treatment, but also a medical document with legal validity. The quality of medical records directly reflects the quality of medical care in hospitals and is an important part of hospital quality control. Through the analysis of 953 end-result medical system discharge end-result quality control, the paper expounds the factors that affect the quality of the medical record and the corresponding measures to improve the medical record quality, and emphasizes the importance of quality control.