摘要
目的探讨外科住院医师病历书写中诊断缺陷原因及对策,以提高外科住院医师病历书写水平和诊断能力。方法抽查某院2015年1月至2015年10月100份外科病案,评阅病案,查找病案中的诊断缺陷,分析原因并提出对策。结果出现诊断缺陷354个。主要的缺陷有病例特点未归纳(21.47%)、诊断依据未归纳或不充分(18.93%)、未验证诊断(13.84%)、诊断病名不规范(11.30%)、未补充诊断(9.32%)。结论缺陷原因有不重视外科病历的书写、缺乏扎实的医学理论知识、缺少诊断思维能力的培训。通过加强理论学习、认真书写病历、规范查房讨论和重视病案监管等措施有助于减少外科住院医师的病历书写中的诊断缺陷。
Objective To explore the causes and countermeasures of the surgical resident’s diagnosis defects on medical records writing so as to improve surgical resident’s medical record writing level and diagnosis ability.Methods 100 cases of surgical medical records from January 2015 to October 2015 in a hospital were selected randomly to found the diagnosis defects.The causes were analyzed and the countermeasures were proposed.Results354 diagnosis defects were found.Major defects includes no summed case characteristics(21.47%),no summed or inadequate diagnosis basis(18.93%),unverified diagnosis(13.84%),no standard diagnosis name(11.30%),no supplementary diagnosis(9.32%).Conclusion The causes of defects includes undervalued the medical record writing,lack of medical theoretical knowledge and lack of diagnostic thinking ability training.The measures such as enhance theoretical knowledge learning,serious the medical records writing,standardize the ward round and case discussion,strengthen the medical record management could reduce the surgical resident’s diagnosis defects on medical records writing.
作者
倪俊
Ni Jun(Department of Burns and Plastic Surgery,905th Hospital of PLA Navy,Shanghai 200052,China)
出处
《中国病案》
2019年第2期17-19,共3页
Chinese Medical Record
关键词
住院医师
病案缺陷
诊断
Resident
Defects of medical records
Diagnosis
