摘要
目的调查了解住院病历书写中存在和出现的问题,以便及时整改,确保病历书写质量。方法按照山西省病历质量评分标准,自制住院病历质量检控表,对2009年度所有出院病案进行终末质控,并对缺陷项目进行统计。结果共调查本院2009年度出院病案1405份,病案甲级率为97.96%,乙级率为2.07%,发现病历缺陷2538项。结论提高病历书写质量,要注重医师临床思维的培养和提高上级医师的管理水平;应加强病案环节质量控制,以利于病案书写质量的提高。
Objective To investigate the problems existing and emerging in the writing of hospitalization medical records for timely rectification and improved quality.Methods According to the evaluation criterion of medical records in Shanxi province,the quality prosecution table of hospitalization medical records was developed to conduct final quality control on all the discharged medical records in 2009,and items with defects were statistically analyzed.Results In 2009,there are 2538 defects in 1405 investigated charged medical records,and the rate of Class A and B were 97.96% and 2.07%,respectively.Conclusion The cultivation on clinical thought of physicians and management level of higher physicians should be enhanced,and link quality control of medical records should also be strengthen to improve the writing quality of medical records.
出处
《中国病案》
2010年第10期7-8,共2页
Chinese Medical Record
关键词
病案
终末质控
缺陷
对策
Medical records
Final quality control
Defects
Strategy
