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镇江市急救中心是镇江市唯一正规化建制的院前急救医疗服务机构,年平均回收病案5000余份,且有每年递增1%的趋势。为使院前急救病历科学化、规范化,在对急救医师上交的病历进行质控的基础上将院前急救病历表格化,经过一年多的临床实施,取得了较好的效果,不仅减轻了急救医师的工作量,而且提高了病历质量,为院前急救病历的规范化提供了一条思路。
Zhenjiang Emergency Center is the only standardized hospital emergency medical service in Zhenjiang City. The average annual recovery of more than 5000 medical records, and an annual increase of 1% trend. In order to make the pre-hospital emergency medical records scientific and standardized, based on the quality control of the medical records handed over by emergency physicians, the pre-hospital emergency medical records are tabulated. After more than one year of clinical implementation, good results have been achieved, not only reducing The workload of emergency physicians, but also improves the quality of medical records, providing a train of thought for the standardization of pre-hospital emergency medical records.