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目的通过主治医师查房考核,加强对病房医疗工作的管理,提高住院患者医疗质量。方法对我院22个临床科室的81名主治医师进行查房考核,并总结分析。结果主治医师查房时忽视体格检查占47.6%;没有修改病历和缺乏教学意识均占33.3%;没有提出患者下一步诊疗措施占28.5%;没有重点询问关键病史占23.8%;特殊检查与治疗分析不全面占23.8%;诊断及鉴别诊断分析不充分占19.0%;未对检查结果进行分析占14.3%。结论加强对主治医师的培训,建立主治医师查房考核制度,提高住院患者的医疗质量。
Objective To improve the quality of medical care of inpatients by strengthening the management of ward medical work through the physician rounds examination. Methods A total of 81 attending physicians in 22 clinical departments of our hospital were investigated and analyzed. Results The attending physician ignored 47.7% of the medical examinations on physical examination, 33.3% did not modify the medical record and lack of teaching awareness, 28.5% did not propose the next medical treatment measures, 23.8% did not focus on key medical history, and special examination and treatment analysis Not fully accounted for 23.8%; diagnosis and differential diagnosis of inadequate 19.0%; did not analyze the test results accounted for 14.3%. Conclusion The training of attending physicians should be strengthened, the checkup examination system of attending physicians should be established, and the medical quality of inpatients should be improved.