冰冻切片病理申请单的规范书写与医疗安全

A Discussion on the Standard Documentation of Application Form of Pathological Frozen Section and Medical Security

目的分析冰冻切片病理申请单的填写状况,提高病案管理质量和医疗安全。方法通过检查1998年11月～2008年11月对某病理科冰冻切片病理申请单3816份,发现存在问题。结果有294份冰冻切片病理申请单不合格,不合格率为7.7%。结论冰冻切片病理申请单书写是否完善、规范,直接与病案质量和医疗安全有关。

Objective To improve the quality of medical records management and medical security by analyzing the documentation of the application form of frozen section. Methods 3816 frozen section applications during November 1998 to 2008 years were examined and the existed problems have been found. Results There are 294 frozen section applications are unqualified; the rate of fraction defective is 7.7%. Conclusions There is close relationship between the documentation of frozen section application and medical security.