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目的为了提高出院记录的书写质量,对缺陷问题进行分析,寻找改进策略。方法按照卫生部2010年颁布的《病历书写基本规范》对出院记录的要求,对1217份内科、外科出院记录常见问题进行分析。结果 1217病例中共存在缺陷1365项,最主要的缺陷项目为重要化验结果记录不全占37.95%,主要诊疗经过简单占34.07%,出院医嘱及带药不详占25.13%。结论加强临床医师对出院记录书写规范性和准确性的认识,重视对病案书写记录的培训,对于提高医疗水平和医院管理水平具有重要意义。
Objective To improve the writing quality of discharge records, analyze the defects and find the improvement strategies. Methods According to the requirements of discharge records issued by the Ministry of Health in 2010, “basic norms of medical record writing”, 1217 common problems of internal medicine and surgical discharge records were analyzed. Results A total of 1365 defects were found in 1217 cases. The most common defects were 37.95% of the cases with incomplete records of important laboratory tests, 34.07% of the major clinics, 25.13% of discharged patients’ orders and unknown drugs. Conclusion It is of great significance for clinicians to enhance their awareness of the standardization and accuracy of discharge records and to pay attention to the training of medical record writing records in order to improve medical standards and hospital management.