摘要
目的找出眼科病案存在的缺陷,分析其原因,并提出对策,以提高病案质量和医疗质量。方法收集质控指标、缺陷项目、月份、专科、病案书写医师和住院天数等资料,对眼科病案质量进行回顾性统计分析,从科学管理的角度提出提高眼科病案质量的对策和方法。结果①统计结果表明:不同月份、专科、病案书写者和住院天数对眼科病案质量有影响;眼科病案缺陷主要集中在首页楣栏和治疗资料两部分。②解决问题的对策包括:强化病案质量意识;重视岗前培训和专业人员引进,提升人员素质;缩短病人住院天数;提高病案首页质量。结论病案具有非常重要的作用,眼科病案存在不少的缺陷,其影响因素是多方面的,应引起足够的重视并采取切实有效的措施加以解决。
Objective To find out the defects existed in medical records in ophthalmic department to analyze the causes and put forward countermeasures. Methods Retrospective statistical analysis and statistical processing of the quality of ophthalmic medical records have been performed according to quality control indexes of medical records, defect items, the month, department, medical record writer, hospitalization days, and the results have also been analyzed. Countermeasures and methods for improving quality of ophthalmic medical records have also been put forward from the point of view of scientific management. Results Statistical results indicate that the month, department, medical record writer, hospitalization days have effects on the quality of ophthalmic medical records, defects of ophthalmic medical records focus on two parts： head page lintel column and therapeutic data. There are some countermeasures to solve these problems： intensifying consciousness for the quality of medical records, attaching importance to training before taking the job and professional indraught, steping up personnel literacy, shortening of hospitalization days, heightening head page lintel column quality. Conclusion Medical records are of very impertantance. There are some defects in ophthalmic medical records, the infection factors are all-round, and we should pay more attention and take effective steps to solve them.
出处
《中国医院统计》
2006年第2期114-117,共4页
Chinese Journal of Hospital Statistics
关键词
眼科
病案
缺陷分析
对策探讨
Ophthalmic department Medical records Defect analysis Countermeasure research
