军队医院病案首页质控前后质量变化统计与分析

摘要

Objective To implement special quality control of the cover page of medical records and precision management of the medical records in our hospital , so as to reduce the defect in the cover page of medical records .Methods Statistical analysis was made on the rate of defects in the cover page of medical records for those patients discharged from the hospital in the first quarter of 2013 and 2014.Results After the implementation of quality control on the cover page of medical records , the number of defects in the cover page was significantly decreased .Conclusion The precision management of the cover page of medical records in direct linkage with the department and individual performance evaluation produced good effects on the improvement of the quality of medical records in the hos -pital.%目的：对海军总医院病案首页进行专项质量控制，实施精细化管理，减少病案首页缺陷率。方法对2013年1－3月与2014年1－3月出院患者病案首页缺陷率进行统计与分析。结果实施首页质控后，缺陷病案首页数量明显下降。结论精细化管理病案首页，并与科室、个人考评挂钩，对提高病案首页质量有很好的效果。