摘要
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 explore the importance of the single item screening method and to increase the writing quality of medical records in the end quality monitoring TMRs. Method Acording to the national , provincial , municipal relevant regulations, using the single item screening method to examine all the medical records one by one. Result Among the 71319 TMRs,9285 of them have different defects including 650 of the second degree and 120 of the third degree, the integral percent reaches 86.98%. Conclusion The single item screening method can assure the integrality of T MRs, can reduse any medical disputes caused by the defects of the medical records.
出处
《中国病案》
2008年第2期15-16,共2页
Chinese Medical Record
关键词
病案质量
单项筛选
the medical records quality
the single item screening
