摘要
目的通过分析8470份手术病案中的质量情况,分析手术病案中的书写缺陷,提出相应对策,狠抓病案书写质量。方法根据《病历书写基本规范》和《江苏省住院病历质量判定标准》,对8470份手术病案逐份检查。结果发现病案缺陷的构成为13.20%,其中重度缺陷占总缺陷的13.51%;主要以住院病案首页填写有缺项、实验室及器械检查漏缺和缺传染病疫情报告记录等缺陷因素构成。结论加强医师规范化培训的学习,提高医务人员对病案重视程度,逐级加强病案质控力度,保证病案书写质量。
Objective To analyze the quality and defects of 8470 copies of surgical medical records,in order to propose countermeasures and improve the quality of medical records.Methods 8470 copies of surgical medical records were checked based on the ＂Basic Norms of Medical Records Writing＂ and ＂Jiangsu Province Quality Criteria of Medical Records＂.Results 13.20% of the medical defects was found,there were 13.51% severe defects in the total defects.The defects was composed mainly of the front sheet of medical record shortage,lab and equipment inspection omit,and lack of infectious diseases report records.Conclusions Basic training on physicians was strengthened.Medical staff should attach great importance to the writing of medical record and improve responsibility,and the quality control of medical records was also strengthened to guarantee the writing quality of medical record.
出处
《中国病案》
2011年第8期22-22,M0002,共2页
Chinese Medical Record
关键词
手术病案
质量分析
对策
Surgical medical records
Quality analysis
Countermeasure
