摘要
目的规范电子医嘱,减少医嘱缺陷及差错的发生,减少或降低医疗事故风险,确保医疗质量。方法随机抽取2013年5月份归档病案500份,按医嘱单书写规范标准对其医嘱部分进行检查,将检查结果录入Excel表中进行统计分析。结果 500份医嘱中366份合格,合格率为73.2%,不合格医嘱中常见的问题依次是医师或护士缺手工签名,占12%;用药医嘱不规范,占11.2%;自定义医嘱,占8.6%;有医嘱无对应的报告单,占8.4%;护理常规、饮食、护理级别不规范,占7.6%。结论通过采取规范医嘱流程、规范医嘱术语及行为、加强院科两级质量管理、增强医务人员的责任心和法律意识等措施,医嘱质量得到提高,医疗安全得到保障。
Objectives To standardize the electronic medical advice, decrease the occurrence of deiects in medical advice, reduce the risk of medical accident and ensure the quality of medical treatment. Methods 500 cases of archived medical records were randomly selected from a hospital in May 2013. To conduct an inspection on the parts of medical advice according to the writing standards in the order sheet, then make statistical analysis on the results of the inspection in Excel table. Results It showed that there were 366 qualified cases in 500 and the pass rate was 73.20%. The common defects of disqualified medical advice included respectively lacking of handwriting signature by the physicians or nurses, which accounted for 12. 00%; not standard medication advice, which accounted for 11.20%; not standard custom advice, which accounted for 8.6%; without the corresponding reports, which accounted for 8.4% and not standard routine nursing, diet nursing and care level, which accounted for 7. 6%. Conclusions Through adopting standard medical advice process, standardizing medical terminology and behavior, strengthening the quality management of both hospital and departments as well as enhancing the responsibility and legal consciousness of medical staff, we could expect the quality development of medical advice and guarantee of medical treatment security.
出处
《中国病案》
2014年第10期23-24,共2页
Chinese Medical Record
关键词
医嘱
常见问题
对策
Medical advice
Common problems
Countermeasures
