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纸质病案在形成、归纳、存储过程中常存在漏项、缺页或遗失等问题,通过制定纸质病案交接要素表、病案质量检查登记表和病案归档信息反馈表,加强实时质控、环节质控和终末质控,以及建立奖罚制度等一系列管理方法,使医护人员责任心和病案书写质量得到进一步提高,杜绝纸质病案记录页的缺失,有效防范了医疗纠纷的发生。为保证病案资料完整性和真实性以及电子病案环境下纸质病案的管理提供可靠保证。
There are often missing items, missing pages or missing items in the process of formation, summarization and storage of paper medical records. Through the formulation of the paper transfer elements table, medical record quality inspection registration form and medical record filing information feedback form, real-time quality control and quality control Control and end-of-life quality control, as well as the establishment of reward and punishment system and a series of management methods, so that medical staff responsibility and medical record writing quality has been further improved to prevent the loss of paper records record page, effectively prevent the occurrence of medical disputes. In order to ensure the integrity and authenticity of medical records and paper medical records in electronic medical records provide a reliable guarantee.