对1780份出院病案的抽检分析

TO ANALYSIS AND CHECK 1 780 PIECES OF MEDICAL RECORDS

目的加强病案质量监控,提高病案书写质量。方法抽查2004年出院病案1780份,按《广东省病案书写规范》评分标准进行质检评分,达到90分以上为甲级病案。结果甲级病案1733份,甲级率为97.36%,且每季呈逐渐上升趋势。结论由于领导重视,各项规章制度不断完善和落实,严格检查和督促,加强了监控力度,提高了病案的书写质量。

Objective To discuss the means of tightening up the quality control of medical record to improve the quality of record writing. Methods First, checking 1 780 pieces of medical records of 2004, and then grading them by The Writing Standard of Medical Records of Guangdong Province. Grade A is given to those getting 90 or over 90 points. Results There are 1 733 pieces of Grade A medical records, making up 97.36%. And it tends to go up by each quarter of the year. Conclusion Due to the leaders care the improvement and implement various rules and regulations, the quality of record writing has been improved.