论文部分内容阅读
目的了解发生医院感染病历质量存在的主要问题,探讨提高病历质量办法。方法根据《病历书写基本规范》、《医院感染诊断标准》等相关制度要求,制定发生医院感染病历质量控制标准,对960份发生医院感染病历进行检查。结果病历书写医院感染内容普遍不完整、不规范。缺陷率较高的前五项分别为未进行相应病原学检查,缺陷率46.46%;手术前讨论(或小结)未提及医院感染,缺陷率45.10%;特异性检查提示有医院感染情况,有治疗医嘱,病程记录无分析、无诊断,缺陷率32.08%;医嘱中围手术期用药不规范缺陷率25.83%;病程记录对医院感染症状、体征描述不规范缺陷率25.00%。结论加强医师医院感染知识培训,提高认识,规范病历中医院感染内容的书写,并开展发生医院感染病历专项质控,能促进病历质量持续改进,提高医院感染管理水平。
Objective To understand the main problems in the occurrence of nosocomial medical records and to explore ways to improve the quality of medical records. Methods According to the requirements of the “Basic Norms of Medical Records Writing” and “Diagnostic Criteria of Nosocomial Infections”, the quality control standards for medical records of nosocomial infections were formulated and 960 hospitalized cases were examined. Results of medical records writing hospital infection is generally incomplete, non-standard. The first five items with higher defect rate were without corresponding etiological examination, the defect rate was 46.46%. Before the operation discussion (or summary), nosocomial infection was not mentioned, the defect rate was 45.10%. The specific examination suggested the hospital infection, Treatment orders, no records of disease records, no diagnosis, the defect rate of 32.08%; doctor’s advice Perioperative non-standard defect rate of 25.83%; history of hospital infection symptoms, signs of non-standard defect rate of 25.00%. Conclusion Strengthening the training of doctors’ knowledge on nosocomial infection, raising awareness, regulating the writing of hospital infection in medical records, and carrying out special quality control of nosocomial infection records can promote continuous improvement of medical record quality and improve the management of nosocomial infections.