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目的通过复印病案情况的分析指导病历书写人员及质控人员认真书写病历,有重点地进行质量监控。方法采用Excel软件计算百分率与构成。结果复印病案的目的以保险理赔和工伤鉴定为主,复印病案内容主要是出、入院记录、医嘱单、医学影像、手术记录。结论医院要对工伤、有医患纠纷、医疗保险病人的病历书写、影像检查、手术记录等重点监控。
Objective To guide patient records and quality control personnel to write medical records carefully by analyzing the condition of the copy medical records, and focus on quality monitoring. Methods Excel software was used to calculate the percentage and composition. Results The purpose of the copy medical record is mainly insurance claims and work injury identification. The main contents of the copy medical record are out, admission records, medical orders, medical images, and surgical records. Conclusions The hospital should focus on the monitoring of work-related injuries, disputes between doctors and patients, medical records of medical insurance patients, imaging examinations, and surgical records.