7所医院440份病历书写质量分析

Analysis on Quality of 440 Medical Records from Seven Hospitals

目的分析病历书写中存在的问题,为提高病历书写质量提供依据。方法随机抽查7所医院中的440份病历,按有关标准、规定逐项检查评分。结果总评甲级病案率为92.5%,乙级病案为7.5%,无丙级病历。外科系统甲级病历占91.4%,内科占93.6%。死亡病历中甲级病历占87.8%,出院病历中甲级病历占97.1%。结论端正态度,加强责任心是保证病历质量的关键因素。

Objective To analyze the problems in medical record writing so as to provide facts for the improvement in medical record writing＇s quality, Methods From seven hospitals, 440 medical records were drawn out at random, and then were checked item by item according relevant criteria, Results Among the 440 medical records, 92.5% belonged to grade A, 7.5% to grade B, and none to grade C. The rate of grade A was 91.4% in surgical system and 93.6% in internal medicine system. Among the death medical records, the rate of grade A accounted for 87.8%, while it was 97.1% in leaving - hospital records. Conclusion It is the key to the improvement in medical record quality to take up a proper attitude or strengthen responsibility.