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目的通过分析某院终末病案质量,查找病案质量问题产生的原因,探讨提高病案内涵质量的有效对策。方法随机抽取2016年1月-12月11 485份终末病案,根据原卫生部《病历书写基本规范》及某院《住院病历书写质量评价标准》审核评分,统计学方法采用描述性统计进行缺陷质量分析。结果 11485份终末病案缺陷频次总计2411次,缺陷项目比例由高到低依次是病程记录缺陷占47.64%,入院记录缺陷占20.46%,病案首页缺陷占18.71%,医嘱单及辅助检查缺陷占6.72%,知情同意书类缺陷占5.56%,其他缺陷占0.91%。结论完善病案信息系统管理,加强病历书写质量相关内容培训考核,提高医师责任意识、质量意识和法律意识,切实提高病案内涵质量。
Objective To analyze the causes of the quality of the medical records by analyzing the quality of the final medical records and to find out the effective measures to improve the quality of the medical records. Methods A total of 11 485 cases of terminal illness from January to December in 2016 were randomly selected and scored according to the “Basic Norms of Medical Record Writing” of a former Ministry of Health and the “Evaluation Criteria of Hospital Medical Record Writing” in a hospital. Statistical methods were used to carry out descriptive statistics quality analysis. Results The final frequency of 11485 cases was 2411 times. The proportion of defective items was from high to low, accounting for 47.64% of the total, 20.46% of the records of admission, 18.71% of the first page of medical records, 6.72% of the medical orders and auxiliary examinations, %, Informed consent category defects accounted for 5.56%, other defects accounted for 0.91%. Conclusion Improve the management of medical record information system, strengthen the training and examination of relevant contents of medical record writing quality, enhance the doctor’s sense of responsibility, quality awareness and legal awareness, and effectively improve the quality of medical record connotation.