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目的:探讨病案全程监控对病案质量的影响。方法:针对我院病案质量薄弱环节,建立管理组织;加强病案形成的质量控制(环节质控);健全病案质量检查监控制度;病案质量与绩效奖、职称评聘挂钩;建立病案借阅制度等。结果:病案质量得到全面、客观、准确的全程监控管理,改善了病案质量的低劣状况,提高了病案质量,甲级病案率达到95%以上。结论:加强病案质量的全程监控管理,促进了医院管理水平、医疗质量、医务人员素质的提高。
Objective: To explore the impact of monitoring the entire case on the quality of medical records. Methods: To establish a management organization based on the quality of medical records in our hospital, to strengthen the quality control of medical records (quality control of links), to perfect the monitoring and control system of medical records quality, to link the quality of medical records with performance awards and professional titles, and to establish a medical record loan system. Results: The quality of the medical records was monitored comprehensively, objectively and accurately. The quality of the medical records was improved and the quality of the medical records was improved. The number of Grade A medical records reached more than 95%. Conclusion: To strengthen the monitoring and management of medical record quality and promote the improvement of hospital management, medical quality and medical staff quality.