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[目的]规范病历书写,使医疗质量和医疗安全不断提升,促进医院管理制度的落实。[方法]根据《辽宁省病历书写基本规范》、《住院病历质量评分标准》对2007年、2008年运行病历进行质量监控。[结果]2007年检查运行病历1737份,问题病历404份;2008年检查运行病历1596份,问题病历250份。缺陷频次多的内容依次为病历书写规范、三级医师查房制度、知情同意制度、医嘱制度。[结论]应强化病案重要性认识,改进管理措施,提高病案质量。
[Objective] To standardize the writing of medical record, to improve the medical quality and medical safety, and to promote the implementation of hospital management system. [Methods] According to “Basic Norms of Medical Records Writing in Liaoning Province” and “Quality Criteria of Hospital Medical Records”, quality records of medical records in 2007 and 2008 were monitored. [Results] 1737 medical records were inspected in 2007, and 404 were recorded. In 2008, 1596 medical records were inspected and 250 were recorded. Defective frequency content followed by the medical records writing norms, three physicians rounds out the system, informed consent system, doctor’s advice system. [Conclusion] The importance of medical record should be strengthened, management measures should be improved, and the medical record quality should be improved.