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目的了解基层结核病防治病案质量现状及产生的原因,探讨提高病案质量的措施。方法对结核病信息管理系统登记的南平市肺结核病案资料和督导抽查病案资料进行检查分析。结果共核查1 241例病案,有71.4%病案记录书写较简单,描述不祥。资料收集较完整有痰涂片检查报告单(97.4%)、X线检查报告单(97.2%)、治疗管理反馈单(95.6%)、治疗协议书(99.0%)和服药记录卡(95.1%)等;但血常规检查单(48.1%)、尿常规检查单(40.2%)、肝肾功能检查单(87.0%)资料完整性较差;信息系统中病案初始录入及时率97.2%、2月末痰涂片检查录入及时率84.3%、疗程结束录入及时率85.3%;信息管理系统病案与原始手工病案相有2项不符。结论应强化医生责任,提高法律意识;加大人力资源建设,加强病案书写培训和质量管理,加大宣传教育力度,提高病案质量。
Objective To understand the current situation and the causes of the quality of medical records in the prevention and treatment of primary tuberculosis and to discuss the measures to improve the quality of the medical records. Methods Check and analyze the data of tuberculosis cases and supervision and check-up cases of Nanping tuberculosis registered by TB management information system. Results A total of 1 241 cases were checked, and 71.4% of cases were written in a simpler way. Data collection was complete with sputum smear test report (97.4%), X-ray examination report (97.2%), treatment management feedback form (95.6%), treatment agreement (99.0%) and medication record card (48.1%), routine examination of urine (40.2%), liver and kidney function checklist (87.0%) were less complete in data integrity. The initial admission rate of medical records in information system was 97.2%, and sputum in late February Smear check-in timeliness rate of 84.3%, the end of treatment time entry rate of 85.3%; information management system medical records and the original manual medical record there are two inconsistent. Conclusion The doctor’s responsibility should be strengthened and the legal awareness should be enhanced. The construction of human resources should be stepped up. Training and quality management of medical record writing should be strengthened. Publicity and education should be intensified to improve the quality of medical records.