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目的通过统计某三甲医院三年急诊死亡病案数据,分析死亡病案存在的缺陷,提高医院急诊死亡病案质量。方法抽取2012年1月至2014年12月641份急诊死亡病案按照卫生部《病历书写基本规范》和门急诊死亡病历书写质量评分表进行统计分析。结果急诊死亡病案的书写存在死亡原因填写不准确、死亡原因分析不确切(3.28%);患者死亡时间填写在病案首页、抢救记录、死亡记录、病程记录、医嘱、护理记录前后不一致(0.09%);死亡抢救记录完成不及时、或无抢救记录(2.18%);死亡病历讨论记录有内容缺陷(2.65%);知情同意书缺失、或缺医患签字(1.87%);有抢救医嘱、无相应抢救记录(1.72%)等缺陷。结论通过加大急诊病案质控力度、加快急诊电子病历软件开发、增加死亡病历环节质控、加强急诊科科室管理,确保提高急诊死亡病案的内涵质量。
Objective To analyze the defects of death cases and increase the quality of emergency cases of death in hospitals by counting the data of three-year emergency cases. Methods A total of 641 emergency death cases from January 2012 to December 2014 were collected and statistically analyzed according to the “Basic Norms of Medical Records Writing” and the written quality score of death records of outpatient and emergency department. Results The death causes of emergency medical records were not accurately filled in, and the cause of death was incorrectly analyzed (3.28%). The patient’s death time was not matched (0.09%) before and after the records of medical records, death records, ; Death salvage records completed in time, or no rescue records (2.18%); the contents of the record of death records recorded content defects (2.65%); informed consent is missing or missing doctor signed (1.87%); rescue orders, no corresponding Rescue records (1.72%) and other defects. Conclusions By increasing the quality control of emergency medical records, accelerating the development of emergency electronic medical record software, increasing the quality control of death medical record links, strengthening the management of emergency department and ensuring the quality of connotation of emergency medical records.