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目的:通过病历中发生的不良事件及其风险度来评价病历质量,目的为加强病历环节和细节的质控,减少或杜绝病历中不良事件的发生,提高病历书写质量,保证医疗安全,减少医疗纠纷。方法:随机抽查2007-2010年某二级医院住院病历4837份,对其进行不良事件风险评估,对病历的终末质量和环节质量进行综合评价分析,找出影响医疗质量的相关联因素。结果:通过对某二级医院2007-2010年随机抽查的终末病历和病房中运行病历的不良事件风险评估,数据经过统计学处理后P值<0.01,说明总的病历中不良事件发生率年度间逐年减少,有极为显著的差别,证明此种病历评价方法切实可行。结论:病历中不良事件风险评估,是减少病历中不良事件发生的有效办法,可以消除病历书写中存在的医患矛盾和医疗纠纷隐患。
OBJECTIVE: To assess the quality of medical records through the occurrence of adverse events and their risk in the medical record. The purpose is to strengthen the quality control of medical records and details, to reduce or eliminate the occurrence of adverse events in medical records, to improve the quality of medical record writing, to ensure medical safety and to reduce medical treatment dispute. Methods: A random sample of 4837 in-patient medical records of a second-grade hospital from 2007 to 2010 was conducted to assess the risk of adverse events, comprehensively evaluate the final quality and quality of the medical records, and identify the related factors that affect the quality of medical care. Results: According to the risk assessment of adverse events randomly selected in a second-grade hospital from 2007 to 2010 and the medical records in the ward, the data were statistically processed before P-value <0.01, indicating the annual incidence of adverse events Between years to reduce, there is a very significant difference, that medical records evaluation method is feasible. Conclusion: The risk assessment of adverse events in medical records is an effective way to reduce the occurrence of adverse events in medical records, which can eliminate the contradictions between doctors and patients and hidden dangers in medical disputes.