口腔正畸专科病案质量缺陷分析

Analysis of Defects in the Quality of Medical Records in Orthodontic Department

目的对某三级口腔医院正畸专科病案开展质控,分析问题并提出对策,以提高病案质量,规范诊疗过程。方法随机抽取某三级口腔医院2019年1月1日-12月31日归档正畸专科病案600份,按照《中华人民共和国侵权责任法》《医疗机构病历管理规定(2013年版)》以及江苏省病案质控标准—《病历书写规范(第2版)》并结合口腔正畸专科特点制定统一标准开展质控。结果缺陷病案532份,占比88.7%。总缺陷数1330次,平均每份病案缺陷2.22项。其中知情同意书缺陷728次,占总缺陷数的54.74%;诊断治疗过程缺陷602次,占总缺陷数的45.26%。主要缺陷问题有:正畸治疗知情同意书无替代治疗方案发生率最高,占比25.71%;其次为治疗记录中无沟通内容,占比18.87%;监护人签字者无双方关系证明,占比13.38%;X线投影测量分析漏填,占比10.98%。结论正畸科医师的法律风险意识较弱,对规范病历书写的重要性认识不足。需进一步加大监管力度,着重加强法律法规的培训和风险意识的培养,以切实提高正畸专科病案的书写质量,保障医疗质量和安全。

Objective To carry out quality control on the medical records of orthodontic department in a tertiary dental hospital,analyze the problems and put forward countermeasures to improve the quality of medical records and standardize the diagnosis and treatment process.Methods Six hundred orthodontic medical records filed in a dental hospital from January 1 st to December 31 st,2019 were randomly selected.Quality control was carried out in accordance with the relevant requirements of the"People’s Republic of China Tort Liability Law"and"Medical Record Writing Specification(2 nd Edition)".Results There were 532 defective medical records,accounting for88.7%.The total number of defects was 1,330,and averagely the number of each medical record defects was 2.22.Among them,the number of the informed consent form defects was 728,accounting for 54.74%of the total defects;The number of the diagnosis and treatment process defects was 602,accounting for 45.26%of the total defects.The main defects are:orthodontic informed consent without alternative treatment has the highest incidence,accounting for 25.71%;followed by no communication in the treatment records,accounting for 18.87%;guardian signatures have no proof of bilateral relationship,accounting for 13.38%;X-ray projection measurement analysis missed,accounting for 10.98%.Conclusion The quality of medical records in orthodontic department needs to be further improved.Orthodontics specialists have a weak awareness of legal risks and their understanding of the importance of standardizing medical record writing is insufficient.Supervision needs to be further strengthened,focusing on strengthening the training of laws and regulations and the cultivation of risk awareness,so as to effectively improve the quality of orthodontic medical record writing and ensure medical quality and safety.