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目的加强病案质控,提高医院管理水平,减少医疗纠纷。方法总结2008至2010年归档病案存在的常见问题,提出应对对策,通过加强过程管理,与临床一线医护人员沟通联系,进行病案评比。结果病案合格率由73%提高到97%。结论病案质量是医疗质量的具体反映,加强病案质量管理,可减少医疗纠纷,提升医院的内涵管理。
Objective To strengthen quality control of medical records, improve hospital management and reduce medical disputes. Methods To summarize the common problems of filing medical records from 2008 to 2010, and to put forward countermeasures. By strengthening the process management and communicating with the first-line clinical staff, the medical records were appraised. Results of the medical record pass rate increased from 73% to 97%. Conclusion The quality of medical records is a concrete reflection of medical quality. Strengthening quality management of medical records can reduce medical disputes and improve the connotation management of hospitals.