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目的检查病历终末质量,探讨单项筛选的重要性,提高病历书写质量。方法参照国家、省、市有关病历书写规定,采用单项筛选法,对所有出院病案进行逐份检查。结果在71,319份病案中,发现9285份有不同程度的缺陷,其中乙级病历650份,丙级病历120份,病案完整率为86.98%。结论单项筛选法可以保证病案的完整性,减少由于病历资料的缺陷而造成的医疗纠纷。
Objective To check the quality of the end of the medical records to explore the importance of single screening and improve the quality of medical records writing. Methods Reference to national, provincial and municipal medical records writing requirements, using a single screening method, all discharged cases were checked. Results Among 71,319 cases, 9285 cases were found to have different degrees of defects, of which 650 cases were in class B and 120 cases in class C. The complete case record was 86.98%. Conclusion The single screening method can ensure the integrity of medical records and reduce the medical disputes caused by the defects of medical records data.