摘要
Abstract
Exposed through medical record medical record medical record number wrong writing quality fil , repetitive or empty, home diagnostic fil are not standardized, fil the wrong item or Loutian, medical advice and consent form signed by not timely filing defects and medical problems;basis"medical records basic norms", combining electronic medical records timeliness, integrity, authenticity and medical instruments regulatory requirements, and strengthen legal awareness, reinforce basic medical, Strict quality aspects, the implementation of quality accountability, according to management medical record and re-reward and punishment and other measures to reduce the occur ence of defects in the medical record, to avoid medical disputes and ensure medical safety, in order to improve the quality of case management science, specifications, safety requirements.关键词
病案管理/质量缺陷/环节质控/对策Key words
Case management/Quality defects/Part of quality control/Countermeasures
