日间手术病历质控难点及应对策略

摘要

通过积极学习相关政策法规,结合医院自身特点,制定和维护日间手术病历模板,加强日间手术病历书写培训,建立日间手术病历监控平台,多渠道反馈质控信息,多措并举,促进病历质量提升.同时,在工作中应及时发现日间手术病历质控中存在问题,结合实际,分析原因,制定改进措施,把好日间手术病历质量关,为日间手术顺利开展提供了重要保障.%Through active learning of the state policies and regulations,combining with the characteristics of hospital,medical record templates for daytime surgery were established and maintained,surgery medical record writing training was strengthened,the medical records monitoring platform was established,multi-channel quality information feedback was carried out,which promoted the quality improvement of the medical record.The problems existing in the quality control of the daytime surgery medical records were timely found,combining the reality of the hospital,the reasons were analyzed,improvement measures were made,the good medical record quality was kept,which provided the important guarantee for the smoothly performing of the daytime surgery.