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目的查找归档疗案缺陷原因和改进方法,持续改进与提高疗案质量。方法对2010年1月-2013年10月归档疗案6419份,按照卫医政发[2010]11号《病历书写基本规范》和《军队医院病历书写与管理规则》逐份进行质量检查,查找缺陷,并对缺陷项目进行分类统计,计算出各类缺陷的构成比。结果疗程记录缺陷1406项,占38.73%;基本要求缺陷756项,占20.83%;各科检查缺陷408项,占11.24%;检查治疗单缺陷389项,占10.72%;医嘱缺陷124项,占3.42%;首页缺陷294项,占8.10%;医师未及时手写签名253项,占6.97%。部分医师质量意识缺乏,基本功不扎实,工作作风不严谨,上级医师把关不到位等因素是疗案缺陷的主要原因。结论全面构建质量管理体系,加强质量意识的培育和基本功训练,建立和完善质量评价标准,实施特勤疗案全程质量管理,持续改进和提高疗案质量。
Objective To find out the causes of defect and the improved methods of archival treatment, to improve continuously and improve the quality of treatment. Methods A total of 6,419 cases were filed from January 2010 to October 2013. According to the Basic Medical Record Practitioners’ Guidelines [11] and the Military Medical Records Writing and Management Rules Defects, and the classification of defects in the project statistics to calculate the composition ratio of various types of defects. Results There were 1,406 defects recorded in the course of treatment, accounting for 38.73% of the total; 756 basic defects were found, accounting for 20.83%; 408 defects were examined in all subjects, accounting for 11.24%; 389 defects were examined and treated, accounting for 10.72%; 124 were medical defects, accounting for 3.42 %; Home defects 294, accounting for 8.10%; Physicians did not handwritten signature 253, accounting for 6.97%. Some physicians lack of quality awareness, basic skills is not solid, the work style is not rigorous, superior doctor check is not in place and other factors is the main cause of defects in the treatment. CONCLUSION A comprehensive quality management system has been established to enhance the cultivation of quality awareness and training of basic skills, establish and improve quality evaluation standards, implement full quality management of special care cases, and continuously improve and enhance the quality of treatment cases.