病历检查中常见的医院感染问题

Nosocomial Infection Problems Found in Terminal Patients Records Inspection

目的从终末病历检查中发现医院感染漏报的原因、病程管理问题及抗菌药物使用缺陷,加强管理,减少医院感染的发生。方法检查2008年1月1日-12月31日出院的患者病历,将问题总结并及时向科室反馈。结果全年有5995份病历检查发现问题,经直接与临床科室沟通,纠正病历书写问题、提出诊疗偏差。结论终末病历检查在弥补医院感染前瞻性监测与目标性监测、规范抗菌药物使用、监测特殊耐药菌等医院感染管理方面有很好的作用。

OBJECTIVE To check the defects of nosocomial infections reports, recording of the patient＇s history, and antibiotics usage, so as to improve hospital management and reduce nosocomial infection. METHODS Patient＇ s records from Jan 1, 2008 to Dec 31, 2008 were reviewed to find out the defects and feedback to the physicians. RESULTS Some problems of 5995 cases were checked out and corrected, some suggestions were made. CONCLUSIONS Checking the patientrs records may supplement the defects of prospective monitor, direct the antibiotics therapy, and monitor occurrence of drug resistance.