1415份病案质量检查分析

目的提高病案管理质量,提高病历书写质量。方法随机抽查2004年我院各临床科室出院病人的1415份病案进行统计。结果1415份病案中甲级病案1394份,乙级21份,甲级病案率98.5%,乙级病案率1.48%。结论分析病案缺陷的主要问题,提出对策以利于病案书写质量的提高。

Objective To improve the quality of the medical record management and that of the documentation medical record writing. Methods The 1415 medical records The Center Hospital of LuoYang 2004 in were randomly checked. Results 1394（98.5%） documents in good quality were found in the total 1415 medical records, 21（1.48%）are in poor quality. Conclusion The analysis the problems existed in the medical records is benefit to improve the quality of the medical record.