整合多种方法提高病历质检效果-《中国卫生质量管理》

文章信息/Info

摘要:: 目的整合多种病历质检方法，实施整体质检模式，解决病历质检方法形式单一、检测内容重复、缺乏关联性、质检效果和病历质量改进不理想等问题。方法将现场临检、运行点检、接收普检和终末抽检整合为一体，根据各种病历质检的形式、特点，应用信息技术，创新检测方法，改进质控模式，优化评价标准原则，设计整体质检方案。结果规范质检模式，避免重复，突出特点，统一标准，共享数据，形成全过程、多环节、多形式、多维立体、联合互补、前后衔接的质控新模式。结论提高了病历质检效果，促进了病历质量改进。

Abstract:: ObjectiveMultiple quality control methods were integrated and entirety quality control mode was implemented to solve the problems including single form of quality control method used, duplication of assessment content, lack of relevance, poor effect of quality control and quality improvement, etc. MethodThe field rummage, running inspection, assessment for all receiving medical records, and sampling quality control of the terminal medical records were integrated. The overall quality control scheme was designed according to forms and features of medical quality control, and in accordance with the application of information technology, innovative detection methods, improvement of quality control model, and optimized evaluation standard.ResultVarious methods of quality models, content, and focus were specified to avoid duplication, promote characteristics, unify standard, and share data, in order to form a whole process, multi-link, multi-form, multi-dimensional, complementary joint, back to back quality control mode. ConclusionThe effect of medical records quality control was improved, and quality improvement was enhanced.

［1］王金声,姜美玉.病历书写质量控制的问题及对策［J］.中国病案,2005，6(3):15-16.

[1]张佳慧赵阳汤罗嘉王艺.复旦大学附属医院内部医联体模式探索与建设[J].中国卫生质量管理,2020,27(02):127.[doi:10.13912/j.cnki.chqm.2020.27.2.38]