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中医病案质量出现问题,其主要原因不外乎责任和能力两大方面。责任体现在不及时书写相关记录、不真实记录或病案中多处刀刮涂改、拷贝病历、重操作轻记录等方面;能力主要是由于病案书写者的中医基本功、专业技能、临床经验及文化修养水平不够所致。本文探索通过加强事前控制、加大环节病案质控力度,建立以病区质量监控为基础、环节质量监控为重点,终末质量监控为辅的过程监控方式,提高医院病案质量。
The main reason for the quality of the medical record of TCM lies in two aspects: responsibility and ability. Responsibility is reflected in the inability to write relevant records, untrue records, or illness records in many areas such as knife-scraping, copying medical records, and recording records of minor operations; the ability is mainly due to the basic skills, professional skills, clinical experience, and cultural cultivation of the medical record writers. The level is not enough. This article explores how to strengthen the quality control of hospitals by strengthening advance control and intensifying the quality control of medical records, establishing a process monitoring method based on quality monitoring of the wards, quality monitoring of links, supplemented by terminal quality monitoring, and improving the quality of hospital medical records.