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目的通过对我院终末病案上级医师查房记录进行质量分析,以提高病历书写质量和临床诊疗水平。方法回顾性分析我院2011年1月至2012年7月746份终末病案上级医师的查房记录,查找所存在的缺陷和不足。结果上级医师查房记录中主要存在的问题包括:(1)上级医师查房记录时间不按时;(2)查房医师的姓名和专业技术职务记录不完全;(3)对患者病史、症状和体征的补充记录不完整;(4)对诊断依据及鉴别诊断缺乏分析;(5)记录中套话较多,无实质性指导意义。结论上级医师查房记录中存在的问题涉及多种原因,应采取针对性的综合有效措施才能不断提高病历书写质量。
Objective To improve the quality of medical record writing and clinical diagnosis and treatment through the quality analysis of physician ward round records in the terminal medical record in our hospital. Methods A retrospective analysis of our hospital from January 2011 to July 2012 746 terminal illness record physician rounds records to find the shortcomings and deficiencies. Results The main problems in superior physician rounds of record-keeping include: (1) the physician’s round-trip recording time is not on time; (2) the physician’s name and professional and technical record are incomplete; (3) the patient’s medical history, symptoms and (4) lack of analysis on the basis of diagnosis and differential diagnosis; (5) more idioms in the record, without substantial guiding significance. Conclusion There are many reasons for the problems existing in the physician ’s rounds of examination. Records should be continuously improved in a comprehensive and effective manner.