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目的探讨和完善病案首页质量控制体系,提高病案首页信息内涵质量。方法制定一套按信息类型分类、百分制细化的病案首页质量评分标准,采取普查和抽样检查相结合的方式,每月进行病案首页质量评比,质量检查与质控考核分离,由出院科室负责病案首页质量。结果医院管理层和临床科室高度重视,病案首页质量整体提升,全院各科得分均在90分以上,最高平均得分为99.9分。结论病案首页质量控制体系依托系统过程控制、加强病案首页质量培训、实行四级监控制度和集合所涉及医务人员的努力,实施效果显著,具有很好的示范作用。
Objective To explore and improve the home page quality control system of medical record and to improve the quality of home page information of medical record. Methods To develop a set of quality criteria for the first page of medical records classified according to the types of information and refined by percentiles. The census and sampling check were used to combine the quality of the first page of the medical record with the quality control and quality control examination. The discharge department was in charge of the medical record Home quality. Results Hospital management and clinical departments attach great importance to the overall quality of the first page of the medical record, all the subjects scored 90 points or more, the highest average score of 99.9 points. Conclusion The first page of the medical record quality control system relies on the systematic process control, strengthens the homepage quality training of the medical record, implements the four-level monitoring system and the efforts of the medical staff involved in the collection. The implementation effect is remarkable and has good demonstration effect.