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目的分析我院机打病案的缺陷,探讨提高机打病案质量的有效方法。方法以卫生部《病案书写基本规范》为标准,对我院使用机打病案系统后9个月病案进行质量检查并作统计分析。结果在10413份终末机打病案中,缺陷病案共2718份,过分依赖书写模版,病案过于框架化,病案拷贝是存在的主要问题。结论应重视机打病案的规范化管理,加强部门之间的沟通,提高医师的思想认识,强化基本功训练,辅以严格的奖罚制度方面入手提高病案质量。
Objective To analyze the shortcomings of machine homicide case in our hospital and discuss the effective ways to improve the quality of case homicide case. Methods Based on the “Basic Norms of Medical Records Writing” issued by the Ministry of Health, the quality of the medical records was analyzed 9 months after the use of the computerized medical record system in our hospital for statistical analysis. Results In 10,413 PDAs, there were 2,718 defective cases, over-relying on writing templates, overly framed cases and copying of medical records were the main problems. Conclusions Should pay attention to the standardized management of computerized medical records, strengthen the communication between departments, enhance the doctor’s ideological understanding, strengthen the training of basic skills, supplemented by a strict system of reward and punishment to improve the quality of medical records.