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目的探讨病历书写中存在的主要缺陷,分析原因,提出相应对策,提高病案质量。方法按照中国医院协会病案管理专业委员会《住院病案书写评估标准》和北京市卫生局下发的《住院病历书写质量评估标准》逐份对2008年出院病案进行终末质控,对存在问题项目进行统计,分析。结果7,860份病案中,缺陷病案287份,缺陷项目425条。结论为使现阶段病案质量在现有基础达到更高水平,需要做以下工作:加强法制观念教育;开展病历书写专题讲座;规范使用专科表格病案;加强环节质量控制;做好终末质控工作,及时发现问题、及时纠正。
Objective To explore the main shortcomings in the writing of medical records, analyze the causes and put forward corresponding countermeasures to improve the quality of medical records. Methods According to the “Evaluation Criteria for Inpatient Medical Record Writing” of the Medical Records Management Committee of the Chinese Hospital Association and the “Evaluation Criteria for Inpatient Medical Record Writing” issued by the Beijing Municipal Health Bureau, the final quality control of the discharged medical records in 2008 was carried out, and the existing problems were carried out Statistical Analysis. Results Among 7,860 medical records, there were 287 medical records of defective medical records and 425 medical records of defective medical records. Conclusion In order to achieve a higher level of existing medical records at the present stage, we need to do the following work: strengthening the education of the concept of legal system; conducting lectures on medical record writing; regulating the use of medical records in special forms; strengthening the quality control of the links; , Discover the problem promptly, correct promptly.