摘要
目的 :了解病历书写缺陷 ,以便采取有效措施提高病历质量。方法 :回顾性调查 6 348份住院病历的入院记录、病程记录、诊断、治疗、手术及抢救记录等书写质量。结果 :发现缺陷少于 5项的病历 3836份 ,占 6 0 4 3% ,其中仅 1项缺陷的 2 76份 ,占 7 19% ;5～ 10项缺陷的 2 5 12份 ,占 39 5 %。按轻、中及重度缺陷分类 ,轻度缺陷病历占97 6 7% ,中度缺陷占 2 33% ,无重度缺陷病历。入院记录、病程记录、出院记录的缺陷率分别为 1 10 7%、0 84 2 %、0 2 16 % ,高于诊断、治疗、死亡及其讨论等记录缺陷率 (0 0 0 4 %～ 0 183% )。结论 :病历书写缺陷与实习医师、进修医师及本院临床医师素质密切相关。提高病历书写质量的关键在于加强临床医师素质培养 ,提高诊疗水平 ,严格执行病历书写规范 ,主动查找缺陷 ,并及时纠正。
Objective:To analyze the defect factors of the medical record.quality and further raise it's qualith.Methods The retrospective studies handwriting defect of hospitalization medical record 6348 ceses.in 2000,including the hospitalization recordance,progressnote,diagnosis,treatment,operation,rescue,and so on Results:Among them 3836(60.43%)ceses were defect 1～4 naps,2512(39.57%)ceses were defect 5～10 naps;6221(97.67%)ceses were light degree defect,148(2.33%)ceses were middle degree defect.The hospitalization recordance,progress note,discharge recordance defective rate were 1.107%,0.842%,0.216%,respectively;diagnosis,operation,death recordance defective rate were 0.183%,0.021%,0.011%,respectively.Conclusion:The medical record defect were close correlation for clinician predisposition The measure necessary to:raise medical recording.quality were as following inprove the training clinician and intern,strich handwriting specification,redress defect in time,and so on.
出处
《华西医学》
CAS
2004年第2期238-239,共2页
West China Medical Journal
