摘要
目的了解死亡病案质量问题。方法对240份死亡病案质量进行回顾性调查分析。结果 240份死亡病案中出现质量缺陷为:抢救或死亡记录内容有缺陷占52.08%,死亡讨论过于简单占12.92%,死亡时间不一致占8.75%,无最后诊断占10.42%,重要检查结果无记录或无分析占13.33%,应有而无患者授权委托书或签名者非被委托人占10.42%。结论加强对死亡病历的书写,重视是根本,措施是关键,落实、监督是保证。所有的医务人员应该认真按规范书写各种医疗文件。
Objective To investigate the quality of death medical records.Methods The quality of 240 death medical records was retrospectively analyzed.Results The defects among 240 death medical records were rescue or death records（52.08%）,too simple death discussion（12.92%）,inconsistent death time（8.75%）,no final diagnosis（10.42%）,important examination results with no records or analysis（13.33%）,and authorized person with no power of attorney or the signature of patients（10.42%）.Conclusion The writing of death medical records should be strengthened,value is the root,measure is the key,and implementation as well as supervision are the guarantee.All medical staff should fill various medical documents carefully according to the standardization to improve the quality of death medical records.
出处
《中国病案》
2010年第10期10-11,共2页
Chinese Medical Record
关键词
死亡病案
质量
缺陷
分析
Death Medical Records
Quality
Defect
Analysis
