【摘要】 目的 比较加强医疗质量管理前后的病案撰写质量。 方法 采用系统抽样的方法，分别抽取2002年7～12月和2004年7～12月的住院病史各126份，进行前后对照研究。 结果 干预前2002年病案撰写质量平均得分92.23分、甲级率90.48%，干预后2004年病案撰写质量平均得分94.84分、甲级率97.62%，两组间存在显著性差异。 结论 通过加强医疗质量管理，综合应用各种管理措施，可明显提高病案撰写质量。

    【关键词】 医疗质量管理;管理措施;病案质量

    A study on the active administrative supervising in qualification of the medical history records

    LI Mei-fang，DING Fu-hao，GUO Jian.

    Zhou Pu Hospital，NanHui District，Shanghai201318，China

    【Abstract】 Objective To confirm the effect of active administrative supervising in the qualification of medical his-tory records.Methods By means of random enrollment of hospital medical records，126records collected from July to December2002(before supervising intervention)and126records from July to December2004(after supervising in-tervention)were analyzed in the comparison for records qualification.Results Good history records were increased from92.23points before supervising intervention to94.84points after intervention with excellent records rates in-creased from90.48%to97.62%before and after interventions.Both data are statistically significant.Conclusion Active administrative supervising is indispensable to the qualification of medical history records. ......