论文部分内容阅读
目的对终末病历存在的缺陷分析,提出相应对策以提高病历书写质量。方法根据卫生部的《病历书写基本规范》为标准,和《内蒙古自治区三级综合医院评审手册》中的《住院病历书写质量检查表》,对2013年第四季度7140份终末病历进行质量检查、分析,找出缺陷,制定计划并反馈给科室。结果 7140份终末病历中,缺陷病历共4230份,临床医生过度依赖电子病历模版,粘贴是病历质量缺陷的主要问题。结论加强病历书写规范化培训,严格重视电子病历的规范化管理,加大病历书写质量的奖罚制度,以提高病案内涵质量。
Objective To analyze the defects of the final medical records and put forward corresponding countermeasures to improve the quality of the medical records. Methods According to the “Basic Medical Records Writing Criteria” of the Ministry of Health as the standard, and the “Inpatient Medical Record Writing Quality Checklist” in the “Inner Mongolia Autonomous Region General Hospital Review Manual”, the quality inspection of 7140 final medical records in the fourth quarter of 2013 was conducted , Analyze, identify defects, develop plans and feedback to the department. Results Of the 7140 final medical records, there were 4230 medical records with defects. Clinicians relied too much on the electronic medical records templates. Pasting was the main problem of medical records quality defects. Conclusion To strengthen the standardization of medical records writing, pay strict attention to the standardized management of electronic medical records, and increase the reward and punishment system of medical records writing in order to improve the quality of medical records.