住院病人检查检验报告单归档的管理

Filing the Laboratory Report of the Inpatients in Time

目的提高病案质量,防范医疗纠纷。方法从2005年1月～2007年12月30,357份住院病案中随机抽取1500份病案进行调研。结果有40份病案检查检验报告单缺失,主要有病人原因、医生原因及辅助科医生原因,分别各占43.8%、37.5%、18.7%。采取相应对策,保证住院病案的完整性,使得检查检验报告单能够及时归档,提高医院甲级病案率。结论病案质量问题应该引起医院管理者、病案管理人员、医护人员的重视。

Objective To improves the quality of the medical record, and protect the medical disputes. Methods We drew 1500 medical records from 30,357 medical records from January, 2005 to December, 2007 at random and studied and researched them. Results We found the deletions of the laboratory sheets in 40 medical records. The reasons of the deletions are in three aspects： caused by the patients, the physicians and the doctors in auxiliary departments. They account for 43.8%, 37.5 % a report nd 18.7%, respectively. We took the corresponding countermeasure to guarantee the integrity of the medical record in the hospital, and file the laboratory sheets in time. As a result, we keep the medical record management of our hospital in A - grade. Conclusions The quality of the medical record is an important in the hospital management. The administrators, the medical record personnel, and the health care personnel＇s should pay special attention to it.