2002～2004年某院病案质量的模糊评判

Vague Judgment on the Quality of the Medical Records in our Hospital from 2002 to 2004

目的为了提高病案、医疗质量,防范医疗纠纷。方法对某医院2002～2004年住院病案首页、病历、病程记录、其它内容四大方面的病案质量试用模糊数学的原理、方法进行评判。结果较全面、合理、科学和准确地反映出各科室的病案质量情况。结论对提高病案、医疗质量提供了确切的依据和整改意见及建议。

Objective To improve the qualities of the medical record and medical treatment and to prevent the medical disputes. Methods By using the principle and method of vague mathematics, we judged the qualities from the front sheet, clinical records, progress notes and other contents in the medical record during 2002 to 2004 in a hospital. Results This paper reflects the qualities of the medical records, and our results were more overall, reasonable, scientific and accurate than before. Conclusion This paper provides exact evidences and suggestions to improve the quality of medical records.