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目的通过麻醉记录书写中的常见问题进行分析,找出麻醉记录的质量要素,方法抽查2004年我院全年的麻醉记录800份,对照有关标准检查。结果800份麻醉记录中585份存在不同程度的缺陷,占所检查记录的73.13％。讨论麻醉记录质量缺陷现象比较普遍,要提高书写质量,首先要提高对病案重要性的认识,其次要加强各级的管理,从制度和机制上解决问题,并强调三级质控网络的实施。
Objective To analyze the common problems in the writing of anesthesia and find out the quality factors of anesthesia records. The method was used to spot-check the 800 anesthesia records of our hospital for the whole year of 2004 and check them against relevant standards. Results There were 585 defects in 800 anesthetic records, which accounted for 73.13% of the records. It is relatively common to discuss the quality defects of anesthesia records. To improve the quality of writing, we must first raise the awareness of the importance of medical records. Second, we must strengthen management at all levels to solve problems from the systems and mechanisms, and emphasize the implementation of three-level quality control networks.