论文部分内容阅读
目的了解病历环节质量现状,分析运行病历存在的缺陷,探讨提高病历环节质量的有效方法。方法随机抽查2008年1月至2009年12月临床各科运行病历1920份进行缺陷分析。结果 1920份运行病历中,优级病历1754份,占91.4%,良级病历166份,占8.6%,无丙级病历。结论重视运行病历的规范化管理,是保证医疗质量,确保医疗安全的前提。
Objective To understand the current status of medical record links and to analyze the shortcomings of running medical records and to explore effective ways to improve the quality of medical record links. Methods randomly selected from January 2008 to December 2009 clinical departments operating records of 1920 cases of defect analysis. Results Among the 1920 operating records, 1754 were excellent medical records, accounting for 91.4%, and 166 were good medical records, accounting for 8.6%. No medical records were recorded. Conclusion The emphasis on standardized management of medical records is a prerequisite for ensuring medical quality and ensuring medical safety.