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目的调查围手术期管理现状,分析围手术期管理重点监管环节,确保手术安全。方法根据围手术期相关管理制度制定《围手术期管理质量调查表》,对三家二级医院手术病历从术前、术中、术后三个阶段管理情况进行统计、分析。结果围手术期管理缺陷术前阶段主要为术前讨论缺陷(51.38%),术中阶段主要为植入性医疗器械登记表填写缺陷(10.09%),术后阶段为生命体征的监测记录缺陷(20.18%)。结论围手术期应加强对病情评估、术前讨论、术后生命体征观察及医患沟通制度的落实等重点环节的监管。
Objective To investigate the status of perioperative management, analyze the key regulatory aspects of perioperative management, and ensure the safety of operation. Methods According to the perioperative management system, a “Surgical Management Quality Questionnaire” was established. Surgical records of three secondary hospitals were analyzed statistically from the three stages of preoperative, intraoperative and postoperative management. Results Perioperative Management Defects preoperatively was mainly discussed preoperatively (51.38%). During the operation, defects were mainly filled in the registration table of implantable medical devices (10.09%), and post-operative monitoring of vital signs was recorded as defects 20.18%). Conclusion During the perioperative period, supervision should be strengthened on the evaluation of the condition, the preoperative discussion, the observation of postoperative vital signs and the implementation of the doctor-patient communication system.