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目的抽查出院电子病案医嘱处理过程常见的缺陷问题,分析原因、提出对策。方法通过医院医嘱系统,抽查部分归档前出院病案1936份,医嘱44529条。主要检查统计缺陷医嘱的类型。结果缺陷医嘱2245条,主要包括医嘱单下达医嘱医师与执行或校对护士漏手签名544频次(24.22%);医嘱单医师或护士签名潦草难以辨认299频次(13.32%);医嘱单书写或修改格式不规范206频次(9.18%)等16类医嘱缺陷。结论医嘱缺陷与医护人员法律观念淡化、能力素质不高、责任心缺失、质控不严密切相关。只有强化医护人员培训、加强法规意识、提高人员素质,规范医嘱流程与行为,才是提高医嘱书写质量,确保医护质量,维护医疗安全的重要保障。
Purpose To check the common defects in the electronic medical record doctor’s order process, analyze the reasons and put forward countermeasures. Methods Through the hospital doctor’s order system, a random sample of 1936 cases were filed before the file was filed and 44,529 doctor’s orders were made. The main types of medical examinations for statistical deficiencies. Results The number of defective orders was 2245, including 544 (24.22%) missed doctors’ orders and missed or missed signatures of doctors or nurses. 299 orders (13.32%) were illegible by doctor’s or nurse’s signature of doctor’s orders; Irregular 206 frequency (9.18%) and other 16 types of medical advice defects. Conclusion Defects in medical advice are not related to weakening legal concept, poor ability and quality, lack of responsibility, and poor quality control. Only by strengthening the training of medical personnel, strengthening the awareness of laws and regulations, improving the quality of personnel and regulating the procedure and behavior of medical orders are the important guarantees for improving the quality of written medical orders, ensuring the quality of medical care and safeguarding medical safety.