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目的分析我院2008年出院病案存在的缺陷,探讨提高病案质量的有效方法及规范化管理的措施。方法按照《广东省病历书规范》的具体要求,对2008年8772份出院病案进行终末质量控制,利用Spss16.0统计学软件对缺陷情况进行统计、归类、分析。结果终末质控病案8872份,缺陷病历1255份(14.31%),缺陷项目1409项(1.12项/每份)。病案缺陷前三位构成依次为病案首页(28.32%)、病情记录(17.03%)、入院记录(12.21%)。结论应建立病案三级质量控制体系,强化病案书写培训,充分发挥信息反馈与奖惩机制作用,提高病历书写质量,防止医疗纠纷的产生。
Objective To analyze the shortcomings in the discharge of medical records in our hospital in 2008 and to explore the effective ways to improve the quality of medical records and the standardized management measures. Methods According to the specific requirements of Guangdong Provincial Medical Record Specification, the final quality control of 8772 discharged medical records in 2008 was carried out. The statistical software of Spss16.0 was used to count, categorize and analyze the defects. Results There were 8,872 quality control cases, 1,255 defective medical records (14.31%) and 1,409 defective items (1.12 items per serving). The first three cases of medical record defects were the first page of medical record (28.32%), the record of illness (17.03%) and the record of admission (12.21%). Conclusions A three-level system for quality control of medical records should be established to strengthen the training of case record writing, give full play to the role of information feedback and reward and punishment mechanisms, improve the quality of medical record writing and prevent the occurrence of medical disputes.