摘要
目的调查上海市某社区卫生服务中心病案质量的现状,提升卫生服务中心病案的管理质量。方法调查对象为上海市某社区卫生服务中心2012年7月-2017年7月收治的300例住院患者病案资料,根据中华人民共和国原卫生部《病历书写基本规范》检查病历书写规范以及知情同意告知的书写缺陷发生率;并细分到病史修改、医嘱取消及更改、辅助检查入院告知、危重患者告知等项目。结果 300例患者的病案资料共出现病历书写缺陷84例,比例28.00%;知情同意告知缺陷52例,比例17.33%。病历书写缺陷的医嘱取消及更改、病史修改不规范、上级医师修阅等缺陷分列前三位,分别占比16例(19.05%)、13例(15.48%)、11例(13.10%);知情同意告知缺陷的入院告知、危重患者告知、手术麻醉告知记录缺陷分列前三位,分别占比14例(26.93%)、12例(23.08%)、11例(21.15%)。结论病案质量检查中主要存在病历书写缺陷及知情同意告知缺陷,以医嘱取消及更改\入院告知记录缺陷为主,需加强社区卫生服务中心的自我管理以及上级卫生部门的监督。
Objective To investigate the medical record quality status in a community health service center of Shanghai and to improve the quality of medical record management. Methods The survey objects were medical records of 300 cases inpatients in a community health service center of Shanghai from July 2012 to July 2017,disease almanac writing standard and informed consent writing defects were checked according to the People＇s Republic of China national health and Family Planning Commission＇s ＂the basic norms of medical records（Trial）＂; and further divided into modify of disease, cancellation and change of doctor＇s advice, assisted examination admission notification, critical patient notification. Results Among 300 cases clinical data, there were 84 medical records writing defects with a proportion of 28%, 52 informed consent notification defects with a proportion of 17.33%; the top three of medical records writing defects were cancellation and change of doctor＇s advice,nonstandard medical records modification, superior doctor repair defects, respectively donating 16（19.05%）, 13（15.48%）, 11（13.10%）; Admission notification, critical patient notification, anesthesia notification record defects were the top three of informed consent notification defects, respectively accounting for 14（26.93%）, 12（23.08%）, 11（21.15%）. Conclusion Case data quality defects in a community health service center of Shanghai are primarily medical record writing defect and informed consent notification defects, cancel and change of doctor＇s advice, admission notice record defects donate most pat of it, self management of community health service center and superior department supervision shall be intensified.
作者
祝静
徐言民
Zhu Jing;Xu Yanmin(Department of General, Community Health Service Center, Zhujiajue Town, Qingpu District, Shanghai 201700, China)
出处
《中国病案》
2017年第12期20-23,共4页
Chinese Medical Record
基金
上海市青浦区区科委课题(PKJ2011-Y24)
关键词
社区卫生服务中心
病案质量
现状分析
Community Health Service Center
Medical record quality
Current situation analysis
