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目的:分析病历中存在的缺陷及其成因,找出解决办法,从而提高病历书写质量。方法:医院质控科对266份出院病历进行检查,对发现的缺陷进行统计、归类、分析。结果:266份病历中共计有缺陷364处,涉及住院处工作人员、临床科室医生、护士及医技科室工作人员。结论:根据缺陷的成因、发现问题,有针对性地组织各相关科室进行学习,从而减少同类缺陷的再次发生,进一步提高病历书写质量。
OBJECTIVE: To analyze the shortcomings and causes of medical records, find out the solutions, and improve the quality of medical record writing. Methods: The quality control department of the hospital examined 266 discharged medical records, and statistically analyzed, classified and analyzed the found defects. Results: There were 364 defects in 266 medical records in total, involving hospital staff, clinic staff, nurses and medical staff. Conclusion: According to the causes of defects, we found the problems and organized relevant departments to study in a targeted manner so as to reduce the recurrence of similar defects and further improve the writing quality of medical record.