论文部分内容阅读
目的探讨手术科室缺陷病案的原因,提出整改措施。方法以病历书写规范为标准,对随机抽查的1728份病案的缺陷进行统计分析。结果在1728份病案中,甲级病案率为97%,乙级病案率为3%;缺陷病案1312份,占75.9%;缺陷项目共1522项。结论加强各级医生对病案书写的责任感和质量意识,强化病案的实时监控与考核,严格病案质量三级把关(出科关、入库关、实时监控关),确保病案质量持续性改进,减少医疗纠纷和事故。
Objective To investigate the causes of surgical department defect medical record and propose corrective measures. Methods Based on the standard of medical records writing, the statistical analysis of the defects of 1728 medical records randomly selected was made. Results In 1728 medical records, Grade A case was 97% and Class B case was 3%. There were 1312 cases of defective cases, accounting for 75.9%. There were 1522 cases of defective cases. Conclusion The doctors at all levels should strengthen the sense of responsibility and quality awareness of medical record writing and strengthen the real-time monitoring and evaluation of medical records. Strict examination of medical record quality should be carried out at three levels (out of medical clearance, storage and real-time monitoring) to ensure continuous improvement of medical record quality and decrease Medical disputes and accidents.