病案质量监控与干预在环节控制中的应用分析

摘要

Objective To explore how to improve the management quality of hospital disease.Methods34 627 patients were studied and analyzed in the hospital from January to October 2013,and the problems existed in the quality management of medical records were found.Results 3 134 of the 34 627 cases were found in the examination and the effective intervention measures were found. The number of problems a monthly decline.Conclusion It is an effective way to improve the quality of medical record management by strengthening the training of medical personnel and establishing a sound system of medical record management,strengthening the quality supervision of medical records,and the verification of the identity of patients.%目的：探讨如何提高医院病安的管理质量。方法对某医院2013年1～10月入院治疗的34627名各类患者的34627份病例进行了研究与分析，发现医院病案质量管理中存在的问题，提出改进的办法。结果在34627份病例的检查中发现了3134项问题条目并采取了有效的干预办法。使问题条目的数量逐月下降。结论加强医务人员培训规范病案书写，建立完善的病案管理制度、加强病案质量监督、做好患者身份的核实，是提高病案管理质量的有效办法。