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目的找出住院病历缺陷、原因和对策。方法对2005年1～6月份病案作回顾性报道。结果4366份病历中缺陷病历483份占11.6%,返修后仍有11份占2.27%。结论强化基本功训练、提高法制观念、坚持有效质控是确保病历质量的关键。
Objective To find out the defects, causes and countermeasures of hospital records. Methods Retrospective reports were made on the medical records from January to June 2005. Results There were 483 cases with 483 cases in 4366 cases, and 11 cases accounted for 2.27% after rework. Conclusion Strengthening basic skills training, improving the concept of the legal system, and maintaining effective quality control are the key to ensuring the quality of medical records.