住院病历书写干预措施效果分析

目的了解住院病历书写干预措施效果,以探讨提高住院病历书写质量的措施。方法以可行性和有效性为出发点,拟定干预方案,通过试点干预研究,以评价干预措施的效果。结果干预措施实施后,住院病历书写质量有明显改善。结论预防易发缺陷环节、提高法律意识等措施是改善病历书写质量的有效方法。

Objective To understand the effect of intervention countermeasure on the medical record,and explore the measures for improving the quality of hospital medical records.Method Starting with the feasibility and effectiveness,intervention programs were developed,then through a pilot intervention study,the effectiveness of interventions was assessed.Results The writing quality of hospital medical record has been clearly improved after the interventions were implemented.Conclusion The intervention on defect point,improvement legal awareness are effective measures to improve the quality of medical records.