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目的通过加强书写质量监控,提高急诊留观病案的书写质量。方法根据卫生部及北京市卫生局相关病历书写基本规范的相关要求,对2244份急诊留观病案进行质量检查。结果 2244病案中有309份存在不同书写缺陷。结论提高留观病历书写质量的关键在于合理分配急诊留观人力资源,调整工作流程,提高急诊科医务人员的法律意识和责任心,强化病历书写规范。
Objective To improve the writing quality of emergency medical records by strengthening the writing quality control. Methods According to the relevant requirements of the Ministry of Health and the Beijing Municipal Health Bureau to write the basic medical records, 2244 emergency cases were inspected for quality inspection. Results There were 309 different writing defects in 2244 cases. Conclusion The key to improve the quality of the written medical records is to rationally allocate the human resources in the emergency department, adjust the work flow, enhance the legal awareness and sense of responsibility of the medical staff in the emergency department, and strengthen the writing of medical records.