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目的规范出院记录书写,加强出院记录质量控制。方法依据原卫生部颁发的《病历书写基本规范(2010版)》对出院记录的书写要求,结合相关文献,将出院记录书写缺陷归纳为6种类型,即完整性缺陷、准确性缺陷、一致性缺陷、易读性缺陷、及时性缺陷和混合型缺陷,并据此对1570份归档病案的出院记录进行缺陷调查。结果 754份出院记录存在质量缺陷,缺陷率48.03%。其中完整性缺陷251份(15.99%);准确性缺陷102份(6.50%);一致性缺陷90份(5.73%);易读性缺陷164份(10.45%);及时性缺陷0份(0%);混合型缺陷147份(9.36%)。结论出院记录的书写质量亟待提高,需要解决导致缺陷发生的深层次原因,采取有效措施,提高书写质量。
Objective To regulate the writing of discharge records and enhance the quality control of discharge records. Methods Based on the writing requirements of the Discharge Records issued by the Ministry of Health in the Basic Specifications of Medical Record Writings (2010 Edition), the defects of writing records of discharge records were classified into six types according to the relevant literatures, ie, completeness defects, accuracy defects and consistency Defects, legibility defects, timeliness defects and mixed defects. Based on this, a defect investigation was conducted on the discharge records of 1,570 filing medical records. Results There were quality defects in 754 discharge records, the defect rate was 48.03%. Among them, 251 were completeness defects (15.99%), 102 were accuracy defects (6.50%), 90 were consistent defects (5.73%), 164 were accessibility defects (10.45%), 0 were timely defects ); Mixed defects 147 (9.36%). Conclusion The writing quality of discharge records need to be improved urgently. It is necessary to solve the deep causes of defects and take effective measures to improve the writing quality.