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一、加强医院各级医师对病历书写的规范化要求严把病历质量审阅关为了提高病历的书写质量和病案归档率,要求科室逐级把关,各科主任不断强化书写规范,并强调出院病案三天内归档。我院建立以医务科为主,病案室、护理部三联合的病案质控中心,从提高思想认识入手,采取多种形式和手段,加强业务学习,提高个人素质。每季度进行病案质量大检查,随机抽取归档病案和在夹病历评分,评选结果与科室的奖惩制度挂钩。由于加强科
First, to strengthen the standardization of medical records at all levels of hospital physicians require strict quality review of medical records In order to improve the quality of medical records and the filing of medical records, requiring departmental checks, the subjects continue to strengthen the writing norms, and stressed the hospitalized within three days Archive. In our hospital, we set up a quality control center for medical records with the medical department as the main case, the medical record room and the nursing department as the three parts. Starting from improving our thinking, we have taken various forms and measures to enhance business learning and personal qualifications. A quarterly examination of the quality of medical records, medical records and randomly selected filing medical records in the folder, the results of the evaluation system linked with reward and punishment. Thanks to the reinforcement section