6,453份院前急救病案质量分析

Analysis on the Quality of 6453 Pre-hospital Emergency Medical Records

目的完善院前病案质量标准,明确病案质量管理目标,促进院前急救质量提高。方法回顾性分析2009年1月1日到12月31日的病案质量,共6,453份,总结病案中的缺点或缺陷。结果急救病案中有缺陷病案1,355份,缺陷率为23.6%,病案总体质量令人满意,但缺点和陋习仍然存在。结论病案管理工作中,要文字质量与内涵质量并重;病案质量控制小组应切实履行好职责,完善管理制度,加强培训,提高院前急救病案质量和院前急救质量。

Objective To perfect quality standards of pre-hospital medical records and identify management objects of medical records in order to improve the quality of pre-hospital emergency.Methods A retrospective analysis was conducted on the quality of 6453 medical records from Jan.1,2009 to Dec.31,2009 and the deficiencies were summarized.Results There were 1355 emergency medical records with defects totally,with the defect rate of 23.6%.The overall quality of medical records was satisfying,yet deficiencies and bad habits still existed.Conclusion Equal importance should be attached to text quality and connotation quality during medical records management;the quality control team should earnestly perform its duty,improve management system,strengthen training and apply all appropriate management methods to improve the quality of pre-hospital emergency medical records.