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目的针对性对出院记录书写存在的缺陷问题进行分析,寻找改进对策。方法依据原卫生部颁布的《病历书写基本规范(2010年版)》与军区卫生部《病案质量检查评分细则》,对某医院2012年6月1日至2014年5月31日出院归档前的终末病案9936份,针对病案中出院记录质量进行质控检查统计,共检出出院记录存在缺陷936份(占9.43%),将出院记录按照患者一般信息、入院基本情况、诊疗经过、主要辅助检查结果、病理诊断、出院情况、出院主要诊断、出院医嘱、医师签名等内容,逐项质控检查进行分析统计。结果 936份出院记录存在质量缺陷,按出院记录存在缺陷项目统计依次为重要辅助检查结果漏记109份(占11.66%);诊疗经过不具体106份(11.35%);出院医嘱内容不全103份(11.07%)等16项。结论加强临床医师岗前培训、强化法律意识与责任心、加强临床基本素养的历练、落实三级医师负责制、奖惩并举激发质量意识等措施,对提高病案质量管理与病历书写质量具有重要意义。
Aim To analyze the shortcomings of the written records of discharge records and find out the improvement measures. Methods According to the “Basic Medical Records Writing Criteria (2010)” and the “Assessment Rules for Medical Records Quality” issued by the Ministry of Health of the People’s Republic of China, a hospital was terminated before discharge from June 1, 2012 to May 31, 2014 9936 cases of final medical records, quality control records for the discharge records for medical records, a total of 936 defective records were found (accounting for 9.43%), the discharge records in accordance with the general information of patients, the basic situation of admission, medical treatment after the main auxiliary examination Results, pathological diagnosis, discharge, discharge of the main diagnosis, discharge doctor’s advice, physician’s signature and so on, one by one quality control examination for analysis and statistics. Results Nine hundred and ninety-six cases of discharge records had quality defects. According to the statistics of the discharge records, there were 109 missing cases (11.66%); 106 cases (11.35%) were unspecified; 103 cases were discharged incompletely 11.07%) and other 16 items. Conclusion It is of great significance to improve the quality of medical record management and the writing quality of medical records for clinicians to strengthen pre-service training, strengthen legal awareness and sense of responsibility, strengthen the experience of clinical basic literacy, implement the three-level physician responsibility system and encourage and punish both quality and incentive.