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目的研究某院急诊留观病案质量存在的缺陷,制定科学的管理对策,以提升急诊留观病案质量及管理水平,切实加强医疗安全。方法随机抽检某院2014年1月-2016年1月的急诊留观病案300份,查找缺陷,分析问题成因,提出对策。结果急诊留观病案质量缺陷主要有14项,其中病史书写欠准确占到39.3%、主诉书写不规范占25.0%、查体不全面占24.3%、重点不明确23.0%等。结论急诊留观病案质量急需提高,应针对产生缺陷的原因,制定全面地控制措施,才能有效提高急诊留观病案质量,将医疗纠纷防患于未然。
Objective To study the defects in the quality of emergency medical records in a hospital and to formulate scientific management strategies so as to enhance the quality and management of emergency medical records and enhance the medical safety. Methods A total of 300 cases of emergency medical records in a hospital from January 2014 to January 2016 were randomly selected to find out the defects, analyze the causes of the problems and put forward countermeasures. Results There were 14 main defects in the emergency department, of which 39.3% were ill-written, 25.0% were not standardized, 24.3% were not fully examined, and 23.0% were not clearly defined. Conclusion The quality of urgent medical records should be improved urgently. In order to effectively control the quality of emergency medical records, the medical disputes should be prevented before they occur.