摘要
目的分析手术科室运行病历书写存在问题,提高病历质量。方法根据陕西省卫生厅编写的《病历书写规范》标准,随机抽取1460份手术科室运行病历,进行检查,并对存在问题统计分析。结果1460份病历中,缺陷病历235份,占16.1%。结论加强手术科室运行病历书写的质控,保证病历的及时性、真实性和完整性,是提高科室医疗质量和防范医疗纠纷和事故发生的重要举措。
Objective To improve the quality of the medical records by the analysis of the medical records with defects used for surgery. Methods Following The Criterion of the Documentation of the Medical Record in Shanxi Province, we analyzed the quality of 1460 medical records used for surgery at random. Results 235 records were found defects, which accounts for 16.1% of the total records. Conclusions We should strengthen the quality control of the medical records for surgery to ensures the timeliness, authenticity and completeness of the medical records, which is the important measure for avoiding the medical negligence and disputes.
出处
《中国病案》
2009年第5期17-18,共2页
Chinese Medical Record
关键词
手术科室
运行病历
缺陷
环节质控
Surgical Department
Running Medical Record
Defect
Link Quality Control
