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目的为了进一步提高住院病历书写水平,确保医疗质量和医疗安全的稳步上升,探讨我院病历书写存在问题,提出改进措施。方法通过单项筛选法和终末质量评分法相结合,对我院2005年出院病案,实施全面的终末质量监控。结果在17241份病案中有1570份存在不同程度缺陷,其中乙级病案95份、丙级病案17份。结论提高病案质量的重点在于强化全院医务人员的法律意识,重视病历书写。
Objectives To further improve the level of inpatient records, ensure a steady increase in the quality of medical care and medical safety, explore problems in the writing of medical records in our hospital, and propose improvements. Methods The combination of the single screening method and the final quality score method was used to implement a comprehensive monitoring of the final quality of the hospital in 2005. Results Among the 17,241 cases, 1570 were found to have different degrees of defects, including 95 cases of grade B and 17 cases of grade C. Conclusion The key to improving the quality of medical records is to strengthen the legal awareness of medical staff in the hospital and attach importance to the writing of medical records.