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目的通过对病案流程中各环节的规范化管理以提高病案的工作质量。方法建立健全病案管理规章制度,规范病案管理各环节工作,加强岗位职责,保障病案回收、归档的完整性和及时性。结果规范化的管理增强了病案管理人员责任意识和法律意识,每个工作流程都有章可循,约束了职业行为,减少了差错。结论科学、合理、有效、规范地开展病案管理工作是确保每一份病案质量的关键。
Objective To improve the work quality of medical records through the standardized management of every link in the medical record flow. Methods Establish and improve the rules and regulations of medical records management, standardize the work of medical records management, strengthen job responsibilities, and ensure the completeness and timeliness of medical records recovery and filing. Results The standardized management enhanced the sense of responsibility and legal awareness of medical record administrators. Each workflow was governed by rules and regulations, restricting professional behaviors and reducing errors. Conclusion Scientific, rational, effective and standardized management of medical records is the key to ensure the quality of every medical record.