对病历终末质量监控的看法

My View on the Quality Control of the Medical Records in the Medical Record Department

目的探讨住院病案终末质量控制(以下简称终末质控)的弊端,以杜绝终末修改病历。方法随机抽取住院病案207份,对其缺陷处进行分析。结果本组病案中存在病历书写的缺陷254处。尚有机会修补的137处,涉及115份病案;因缺乏原始资料而不可能再修补的病历占46.1%。结论终末修改病历有弊而无利。建议抓病历书写的基础环节和中间环节,使每一份病案归档时均合格。

Objective To probe the deficiencies of the medical records by the quality control in the medical record department so as to stop the correction of the medical records at the end. Methods 207 medical records were selected at random and analyzed. Results 137 out of 254 deficiencies can be corrected involved 115 medical records, and there are still 46.1% of the problems that can hardly be corrected because of sufficiency of original data. Conclusions quality control should be carried out in wards instead of in the medical record department to ensure that every one meets with the standard before filling.