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目的通过死亡病案审查,分析诊疗过程中存在的问题,提出改进对策。方法选取某院2016年3月-2016年11月的死亡病案329份,按照《广东省病历书写规范》和病案评分表进行检查,分析诊疗过程中的医疗质量情况。结果数据显示329份死亡病案,共8883项审查项目,其中存在缺陷801处,总体缺陷率为9.02%,其中涉及医疗核心制度占比最大,为90.64%,为主要问题所在。结论死亡病案从侧面反映出诊疗过程中存在的主要问题,对策上可以从完善制度修订、前移质量监控重心、推进信息建设三方面着手,从根本上改善医疗核心制度的执行情况,从而提高死亡病案质量。
Objective To analyze the problems in the process of diagnosis and treatment through the review of death medical records and put forward the improvement measures. Methods A total of 329 deaths from March 2016 to November 2016 in a hospital were selected and examined in accordance with the Guangdong Provincial Medical Records Writing Criteria and the medical record rating scale to analyze the medical quality during the treatment. The data showed that there were 329 cases of deaths, of which 8,883 items were reviewed. Among them, 801 were found defective, with an overall defect rate of 9.02%. The most serious problem was the medical core system accounting for 90.64%, which was the main problem. Conclusion The death cases reflect the major problems in the process of diagnosis and treatment. The countermeasures can improve the implementation of the medical core system and improve the death from the aspects of perfecting system revision, moving forward the focus of quality control and promoting information construction Medical record quality.