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病案终末质量管理对提高病案质量及医疗质量至关重要,我院为了提高病案质量管理,建立了临床一线副高职称医师参加病案终末质控工作制度。这一制度的实施,提高了临床专家病案修改水平、病案质控水平和病案质量,进而提高医疗质量,减少和避免了由于病案质量引发的医疗纠纷。我们的体会是,临床专家参加终末病案质控,也是提高医疗质量的一种有效方法。
The final case quality management of medical records is crucial to improving the quality of medical records and the quality of medical care. In order to improve the quality management of medical records, our hospital has established a system for the quality control of end-of-surgery medical practitioners who participate in clinical first-line assistant high-ranking physicians. The implementation of this system has improved the clinical expert’s revision of the medical record, the quality control level of the medical record, and the quality of medical records, thereby improving the quality of medical treatment and reducing or avoiding medical disputes caused by the quality of the medical record. Our experience is that the participation of clinical experts in the quality control of terminal cases is an effective way to improve the quality of medical care.