181份死亡病案相关记录书写缺陷研究

Investigation on Written Deficiencies of Medical Records Related to 181 Death Cases

目的提高死亡病案书写质量。方法采取回顾性死亡病案书写质量调查法。对我院2008年8月到2009年6月出院的死亡病案检查中发现的缺陷原因进行分析。结果死亡病案质量存在的主要问题是部分医师对病历书写规范新知识更新不快,上级医师指导把关不够,部分医师对病历书写重要性缺乏足够重视。结论组织临床医师学习病历书写规范细则,制定死亡病案质量检查标准,加强死亡病案质控力度,建立奖惩制度等多方面措施相结合的方法 ,从而使死亡病历书写质量明显提高。

Objective To improve written quality of death cases.Methods Analysis was done on causes of deficiencies found in examination of death cases discharged from Aug.2008 to Jun.2009 in our hospital with retrospective investigation on written quality.Results Some clinicians had slow updates on new knowledge related to written standardization of medical records;guidance and examination from higher level clinicians were not enough;some clinicians didn＇t pay attention to the importance of written standardization of medical records,there was a phenomena with valued treatment and neglected written quality of medical records,which were the leading problems present in death cases quality.Conclusion It＇s necessary to organize clinicians to learn the details of written standardization of medical records,determine inspection standards of death cases quality,strengthen the intensity of quality control of death cases and establish a rewards and penalties system combining with various measures with significant improvement of written quality of death cases.