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目的调查医疗文书填写现状并探讨其对患者满意度之间的影响。方法 2012年10月-12月以呼吸内科住院的患者为调查对象,调查其医疗文书完成情况,统计医疗文书缺项数目。同时参考国内外患者满意度研究,自制满意度调查表,调查患者对医务人员满意度;分析医疗文书缺项数目对患者满意度的影响。结果研究共纳入151例患者,共有126份医疗文书存在不同程度填写缺陷,占83.44%,平均缺项(11.58±11.63)条。总体患者就医满意度为6.85分,与医疗文书缺项数目呈现负相关性(R=0.602,P=0.001)。患者性别、年龄、文化程度、付费方式和住院天数与患者满意度无相关性。结论医疗文书缺项数目较多、完成质量不高。需要加强医务人员对于医疗文书完成质量的重视程度。
Objective To investigate the status quo of medical documents and to explore their impact on patient satisfaction. Methods From October to December 2012, patients admitted to the Department of Respiratory Medicine were investigated. The medical instruments were investigated and the number of missing medical records was counted. At the same time, referring to the domestic and international patient satisfaction research, self-made satisfaction questionnaire to investigate the satisfaction of patients with medical staff; analysis of the number of medical documents lack of patient satisfaction. Results A total of 151 patients were enrolled in the study. A total of 126 medical documents were filled in with varying degrees of defects, accounting for 83.44% and an average of 11.58 ± 11.63. The overall patient satisfaction rate was 6.85, which was negatively correlated with the number of missing medical records (R = 0.602, P = 0.001). Patient’s gender, age, educational level, payment method and length of stay had no correlation with patient’s satisfaction. Conclusion There are a large number of missing medical documents and the quality of finished products is not high. There is a need to strengthen the degree to which medical staff attach importance to the quality of medical instruments.