摘要
目的了解终末病历质量现状,探讨提高病历书写质量的方法,防范医疗纠纷的发生。方法将本院2012年全年23,154份归档病案按照卫生部颁布的《病历书写基本规范》和《河北省病历书写规范细则》进行质控后做统计、分析,找出存在的问题。结果甲级病案22,957份,占99.15%;乙级病案197份,占0.85%;无丙级病案出现。有缺陷病案共1191份,缺陷项共56项,涉及到医疗纠纷的缺陷项目有24项,外科系统缺陷病案明显多于内科。结论规范病历书写质量管理,加强环节病历质量控制,使病案管理科学化和规范化,从整体上提高病历书写质量,是有效降低医疗风险的关键。
Objective To understand current situation of terminal medical record quality, and discuss methods to improve the quality of medical record writing, prevent the occurrence of medical disputes. Methods A total of 23154 medical records were analyzed and found problems according to ＂Medical record writing basic specifications＂ and ＂Hebei province medical record writing detailed rules and regulations＂ in 2012. Results There are 22957 grade A medical records, accounting for 99.15% ; 197 grade B medical records,aecounting for 0.85%; No grade C medical record. A total of 1191 medical records had defects. The number of defective items was 56. A total of 24 items involved in medical disputes. Surgical defects significantly more than the internal medicine. Conclusion We should make medical record writing quality management norm, strengthen llnk medical record quality control, make the medical record management more scientific and standardization, improve the quality of medical record writing to effectively reduce the medical risk.
出处
《中国病案》
2013年第9期23-25,共3页
Chinese Medical Record
关键词
病历书写
质量缺陷
医疗风险
措施
Medical record writing
Quality defect
Medical risk
Measures
