摘要
目的:探讨抢救记录书写存在的问题,采取有效措施提高抢救记录书写质量。方法:按照《广东省病历书写与管理规范》,对700份有抢救记录的出院病案进行总结分析。结果:在700份抢救记录中,抢救结束未在6小时内补写抢救记录的最多,有50例,占7.1%;其次是医护记录不一致38例,占5.4%。结论:加强医务人员法制宣传,加强病历书写培训,加强运行病历的环节质控,加强奖惩处罚力度,可以有效提高抢救记录书写质量。
Objective To investigate the rescue records written problems and take effective measures to improve the writing quality of the rescue records.Method Summarized and analyzed 700 rescue records discharged from hospital medical records according to the Guangdong Medical Record Writing and Management Specification.Result Among the 700 rescue records,there were 50 cases which were not written within 6 hours accounts for 7.1%,followed by health care records were inconsistent 38 cases,accounts for 5.4%.Conclusions Firstly,raise the attention level of law publicity.Secondly,strengthen the medical staff＇s training of medical records.Thirdly,strengthen the running medical part of quality control.At last,strengthen the incentive penalties,so that we can improve the writing quality of the rescue records effectively.
出处
《内蒙古中医药》
2012年第20期37-37,共1页
Inner Mongolia Journal of Traditional Chinese Medicine
关键词
抢救记录
缺陷
防范对策
Rescue records defects Prevention Countermeasures
