摘要
目的提高医院感染病历的整体质量和规范性,减低医院感染的发生率。方法回顾性调查83份医院感染病历,按2008年"浙江省医院住院病历质量检查评分表"和2009年浙江省"医院感染管理质控检查表"进行检查。结果抗菌药物合理使用记录合格率最低,为72.3%,最高是医嘱单,为96.4%,存在主要问题是病历记录完整性不够,无预防控制措施落实、检验结果无记录、医嘱与病程记录不相应;医护记录不相符。结论加强医务人员的工作责任心和法律意识,加强医院感染知识的培训,提高病历书写水平,加强病历质量监控,以提高病历的完整性、科学性。
OBJECTIVE To improve the overall quality and standard of infection medical records,and reduce the incidence of infection.METHODS A total of 83 infected medical records were investigated and checked according to 2008 version of Quality Inspection Score Sheet of Hospital Medical Records of Zhejiang Province and 2009 Quality Control Checklist of Hospital Infection of Zhejiang Province.RESULTS The lowest pass rate was rational use of antimicrobial agents′ records（72.3%）,the highest was the doctor＇s advice sheet（96.4%）.The main problems were that the integrity of medical records was not enough and there was no control measure.No record of test results and the doctor＇s advice did not correspond with the course record and medical records did not match with each other.CONCLUSION By strengthening the responsible and legal awareness of medical staff,further the knowledge training of hospital infection,raising the level of medical writing and strengthening the quality control of medical records,the integrity and scientific meaning of medical records can be improved.
出处
《中华医院感染学杂志》
CAS
CSCD
北大核心
2011年第6期1187-1188,共2页
Chinese Journal of Nosocomiology
