摘要
目的针对病案首页质量缺陷内容及原因进行分析,制定相应的病案首页规范化管理措施。方法将病案首页质量缺陷内容进行分类统计、剖析。结果7857份病案首页中有444份存在质量缺陷,缺陷率为5.66%,手术情况缺陷率最高。结论病案首页缺陷主要由教学环境、医生医疗水平及疏忽职责等原因所导致。
Objective To analyze the contents and reasons of the defects in quality in the front sheets so as to make corresponding standards and countermeasures. Methods To analyze and calculate the defects of quality in the front sheets of the medical records. Results 444 in 7857 medical records are of defects in quality, taking up 5.66%. The rate of the defective medical records of operation is higher. Conclusion The defects in quality in the front sheets of medical records result from the teaching environment, the practice and ethics of the doctors.
出处
《中国病案》
2005年第3期20-21,共2页
Chinese Medical Record
