摘要
目的：了解某三甲医院目前病案书写的质量情况，分析归档病案存在的缺陷，探讨解决问题及提高质量的对策。方法随机抽查某三甲医院2012年7月～2013年7月的出院归档病案共1510份，对存在缺陷进行统计、分析。结果在1510份归档病案中，甲级病历1493份，乙级病历17份，甲级率98.87%。结论提高病案书写质量，体现医疗文书的价值，维护医患双方的合法权益，更好地为患者和临床、科研服务。
Objective To investigate the quality of medical record writing in a grade-A first-class hospital and analyze the defects of archived medical records to explore countermeasures to resolve above problems and improve quality. Methods 1510 archived medical records of patients discharged the hospital from July 2012 to July 2013 were randomly selected for statistics and analysis of potential defects. Results Among the 1510 archived medical records,there were 1493 grade-A medical records（98.87%） and 17 grade-B medical records. Conclusion The quality of medical records should be improved to demonstrate the value of medical documents,protect legitimate rights and interests of both patients and doctors,and better serve the patients as well as clinical practice and scientific researches.
出处
《中国医药科学》
2014年第3期176-178,184,共4页
China Medicine And Pharmacy
关键词
病历质量
缺陷分析
对策探讨
Quality of medical records
Defect analysis
Countermeasure development
