病案诊断质量分析

         

摘要

为探讨病案诊断质量对医疗质量的影响,本文阐述了根据病案的主要诊断,对医疗质量和单病种费用分别进行了统计和分析。结果显示:诊断存在概念不清、人为拔高、选错诊断,以及诊断名称不规范等问题。这势必影响医院管理者或卫生管理部门的决策,也影响病案资源的利用和共享。%To probe the diagnosis quality of the medical record into the influence of the medical treatment quality, it is expounded in this article that according to the main diagnosis of the medical record, the statistics and analysis were done to the medical treatment quality and the outlay of the single case. The results shown: the concept is not clear in the diagnosis, the diagnosis is raised artificially, the diagnosis is wrong, and the diagnosis name is not criterion, and so on. The decisionmaking of the supervisor in the hospital or the decision-making of the sanitation administer should been influenced, the utilizing and the share of the medical record resource should been influenced, too.

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