摘要
Abstract
The cur ent quality control system of medical record does not ful y go electronic, that perfecting the management of medical records control system is necessary in our hospital. To radical y intensify medical record quality control, reduce the defects of clinical medical record and eliminate the potential medical risk, this research built up four levels quality control system by careful y analyzing the writing defects of medical record and reasonably evaluating medical record quality in ophthalmology hospital. Throughout the process, the quality of medical record was improved by using the plan-do-check action (PDCA) cycle management.关键词
医院病案/质量控制体系/病案质量/PDCA循环Key words
Medical record/Quality control system/Medical record quality/Plan-do-check action cycle
