对5732份病案缺陷分析及对策研究

Defects Analysis of 5732 Medical Records and Countermeasures Study

目的分析成都市某两家医院病案书写现状,探讨其规范化管理的措施。方法抽查2008年出院病案5732份。结果共有缺陷14223项,平均每份病案有2.48项缺陷。基本项目空白或填写不全比例最高,为13.08%。结论加强质量教育和管理力度以提高病案质量,有效地保护医患双方的合法权益。

Objective To analyze the current situation of medical records of two hospitals in Chengdu,and investigate the measures to standardize the management of medical records.Method We made spot check on 5732 discharge medical records from two hospitals in Chengdu.Results There were 14223 defects in the spot-check medical records.Each medical record had an average of 2.48 defects.Basic items were blank or incomplete was the most common defects,which occurred 1860 times and accounted for 13.08% of the total flaws.Conclusion Strengthening education quality and management intensity to improve the quality of medical records and to protect the legal rights of doctors and patients effectly.