院前急救病历表格化应用探讨

Discussion on the Application of Pre-hospital Emergency Form

镇江市急救中心是镇江市唯一正规化建制的院前急救医疗服务机构,年平均回收病案5000余份,且有每年递增1%的趋势。为使院前急救病历科学化、规范化,在对急救医师上交的病历进行质控的基础上将院前急救病历表格化,经过一年多的临床实施,取得了较好的效果,不仅减轻了急救医师的工作量,而且提高了病历质量,为院前急救病历的规范化提供了一条思路。

Zhenjiang Emergency Center is the only formalized pre-hospital emergency medical service agency in Zhenjiang City,with the average annual recovery of more than 5,000 cases and 1% increase trend annually.In order to make the pre-hospital medical records more scientific and standardized,our center adopted the pre-hospital emergency medical form,on the basis of controlling the quality of medical records that first-aid doctors turned over.After more than one year of clinical implementation,good results were obtained,as it not only reduced the workload of emergency physicians,but also improved the quality of medical records so as to provide a train of thought for the standardization of pre-hospital medical records.