摘要
目的:探讨急诊创伤科护士对病案首页填写质量因素与改变对策分析。方法:提取医院2016年急诊创伤科出院病案首页书写不规范情况的记录进行统计分析。结果:损伤外部原因、联络地址、门诊诊断、其他诊断的书写错误位列该院急诊创伤科书写缺陷前五,分析总结出该科室没有正确理解病案首页填写项目的问题。结论:应当优先针对集中错误的项目进行专项培训,提高医护人员的病案首页书写质量。
Objective: To explore the quality factors and countermeasures of emergency trauma nurses on the first page of medical records. Methods: Statistical analysis was performed on the records of irregular situation written on the first page of the discharge case of emergency trauma department of our hospital in 2016. Results: The external causes of injury, contact address, clinic diagnosis, and other diagnostic writing errors in the hospital emergency trauma defect before writing five, analysis summarized the department do not have a correct understanding of medical record home page fill in the project. Conclusion: Special training should be given priority to these centralized and wrong projects to improve the writing quality of medical records.
作者
马莹
MA Ying(Xi'an the Third Hospital,710018,Xi'an 710018,Shaanm Province,P.R.C)
出处
《中国数字医学》
2019年第1期109-110,119,共3页
China Digital Medicine
关键词
病案首页
填写质量
对策
medical record home page
filling quality
countermeasures
