病历质量目前还未被部分医院管理层和医务人员放到医疗质量管理的重要位置,缺乏一种理想的控制手段。本文对落实病历质量责任制的必要性、措施及保证进行了论述,尤其对加强终末质管人员的工作,建立“医师病历质量档案”,把医师的临床工作放到病历质量管理中进行“量化尝试”。 Medical records quality has not yet been part of the hospital management and medical staff into the medical quality management an important position, the lack of an ideal control. In this paper, the necessity, measures and assurances of medical records quality responsibility system are discussed. Especially for strengthening the work of final quality control personnel, the paper establishes the “physician medical record quality file” and puts the physician’s clinical work into the medical record quality management, Quantified attempt. "