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目的通过病案评比结果的分析,探讨提高病案内涵质量的对策。方法随机抽取8月份的出院病案77份,按本院终末质控评分标准评比并对问题做归类总结。结果甲级病案65份,占84.4%;乙级病案12份,占15.6%;丙级病案0份。病案缺陷322条,其中病案内容缺陷272条,占84.4%;时限缺陷36条,占11.3%;首页及其他14条,占4.3%。结论我院病案书写缺陷以内容缺陷为主,病案内容书写的水平反映出病案内涵质量。病案内涵质量是医疗质量管理的关键,如何提高病案书写内涵质量值得探讨。
Objective To explore the countermeasures to improve the quality of the medical records through the analysis of the results of the medical records. Methods Totally 77 discharge cases were collected in August. According to the final quality control score of this hospital, the problems were classified and summarized. Results A grade 65 cases, accounting for 84.4%; B grade 12 cases, accounting for 15.6%; C grade 0 cases. There were 322 medical records, of which 272 were medical records, accounting for 84.4%; 36 were medical records, accounting for 11.3% of the total; and 14 were homepages and 14 others, accounting for 4.3%. Conclusion The defects of the medical record writing in our hospital are mainly based on the content defects. The level of medical record content writing reflects the quality of the medical record connotation. The quality of medical records is the key to medical quality management. How to improve the quality of medical records is worth discussing.