摘要
目的：提高围手术期的病历质量,确保医疗质量的持续改进,减少医患纠纷。方法：按医院设计的表格,先对2010年1~3月围手术期157份病历质量进行专项检查,对缺陷原因进行分析并采取相应的整改措施,再对2010年10~12月整改后的围手术期121份病历质量进行同样检查。比较两组数据并做卡方检验。结果：采取措施后的围手术期病历质量有明显提高,不合格率明显下降,P〈0.01。结论：强化对病历书写重要性的认识、强化法律观念、注重培训;是提高围手术期病历质量,减少医患纠纷的有效方法。
Objective： to improve the operation period of the quality of medical records, to ensure the continuous improvement of medical quality, reduce the medical disputes. Methods： according to the forms designed by the hospital, first on January - March 2010 peri operation period 157 copy of the medical record quality to carry out a special inspection of defects, analyzeing the reasons and taking corresponding measures, and on October - December 2010 peri operation period of 121 medical records quality were similarly examined. Comparison of two groups of data and a chi-square test has been made. Results： after taking measures to surround operation period of medical record quality is obviously improved, the unqualified rate decreased significantly, P 〈 0.01. Conclusion： to strengthen the awareness of the importance of strengthening medical record writing, legal concept, and to pay attention to training is an effective method to improve medical quality in peri operation period, reduce medical disputes.
出处
《安徽卫生职业技术学院学报》
2012年第2期5-6,共2页
Journal of Anhui Health Vocational & Technical College
关键词
医疗质量管理
围手术期
病历书写质控
medical quality management
period of operation
medical record writing quality control
