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目的探讨病案质量控制模式的转变对病案内涵质量的提高及医疗纠纷的防范的重要作用。方法采用积极有效沟通、管理互动,科室横向联合,建立二级纵向质控组织框架等综合的措施,对病案质量进行控制。结果病历缺陷率从27.7%降至13.14%。结论病案质量控制综合模式,能形成管理合力,构建交叉的有学术价值的质控评价体系,最大限度的提高病案书写质量从而提高病案质量管理水平。
Objective To explore the important role of the change of medical record quality control mode on the quality of medical record connotation and prevention of medical disputes. Methods Comprehensive measures such as active and effective communication, management interaction, cross-departmental collaboration and establishment of secondary longitudinal quality control organizational framework were adopted to control the quality of medical records. Results The medical record defect rate dropped from 27.7% to 13.14%. Conclusions The comprehensive medical record quality control model can form a management force and construct a cross-linked quality control evaluation system with academic value to maximize the quality of medical record writing and improve the medical record quality management.