摘要
目的针对术前讨论制度执行情况常见问题,采取有效措施改进。方法对200份手术病历按照《病历书写规范》以及该院的《终末病历评分标准》进行质量检查和统计分析。结果术前讨论记录存在很多问题,与术前讨论存在形式化、医师书写病历不规范、上级医师对下级医师指导作用不强等有关。结论从严格执行术前讨论制度,保障手术安全;加强培训,规范病历书写;完善病历质量评分标准;强化环节质控,确保内涵质量;落实终末质量检查,提高整体质量等进行改进,提高术前讨论质量,保障医疗安全。
Objective To explore effective measures for target improvement,based on common questions in the implementation of preoperative discussion system.Methods Quality inspection and statistical analysis were performed in 200 cases of medical records.Results Many problems existed in the medical records,which were related with formalization of preoperative discussion,irregular writing of medical records and the weakened guidance role of senior doctors to junior doctors,etc.Conclusion The paper suggested to improve from five aspects to enhance the quality of preoperative discussion and to ensure medical safety,which include strict implementation of system for preoperative discussion to ensure surgery safety;enhancing training,standardization of medical records;strengthening quality control of process to ensure content quality;implementation of terminal quality inspection to improve the overall quality.
作者
杨洁
刘秋生
李礼安
肖良成
曾晓静
YANG Jie;LIU Qiusheng;LI Li′an;XIAO Liangcheng;ZENG Xiaojing(The First Affiliated Hospital,Sun Yatsen University,Guangzhou 510080,China)
出处
《实用医学杂志》
CAS
北大核心
2021年第15期2026-2029,共4页
The Journal of Practical Medicine
关键词
术前讨论
质量控制
医疗安全
preoperative discussion
quality control
medical safety
