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目的通过对社区卫生服务机构病案现状分析,讨论对策,提高病案质量。方法 2016年5月随机抽查社区门诊病历180份,按《医联体社区卫生服务基本医疗考核指标》进行检查及统计分析。结果抽查180份社区病历,有93份病历存在缺陷,占检查病历的51.67%,主要表现为:诊断名称不规范及体格检查缺陷各20例,分别占11.11%,复制黏贴缺陷,占8.89%;现病史过于简单,占8.33%;家族史填写不全,占4.44%;主诉不规范及辅助检查缺项,分别占2.78%;健康指导缺乏针对性,占2.22%。结论通过采取医师岗位培训,建立完善的社区病案管理体系,加快社区电子病案信息化进程,实行岗位追责制度等方法,提高社区病案书写质量。
Objective To analyze the current situation of medical services in community health institutions, discuss the countermeasures and improve the quality of medical records. Methods In May 2016, 180 outpatient medical records were randomly selected and examined according to the “Basic Medical Assessment Indicators of Community Health Service in Medical Federation”. Results A total of 180 community medical records were randomly selected and 93 medical records were found to be defective, accounting for 51.67% of the medical records examined. The main symptoms were as follows: 20 cases were diagnosed as non-standard name and physical examination defects, accounting for 11.11%, 8.89% ; The history of the current illness is too simple, accounting for 8.33%; incomplete family history, accounting for 4.44%; the main complaint of non-standard and ancillary items missing, accounting for 2.78%; lack of targeted health guidance, accounting for 2.22%. Conclusion Through taking doctors post training, establishing a perfect community medical record management system, speeding up the process of community electronic medical record informatization, implementing post responsibility system and other methods to improve the quality of community medical record writing.