住院医师病历书写规范程度调查

Survey of the standardization of medical records writing by physicians

目的了解住院医师病历书写的规范程度。方法采用定量与定性分析结合的方法分组抽样调查住院医师病案文书的规范程度。结果住院医师病历书写的可辨认率为82．55%，等级评价的优秀率为24．50％。高年资住院医师病历书写优秀率低于低年资住院医师；评价人有无医学背景知识对医师病历文书书写等级评价结果无显著性差异，而可辨认率存在显著性差异。结论住院医师病历书写中确实存在不规范现象，病历文书的可正确辨认率有待提高。

Objective To study the standardization of medical records writing by residents in hospitals. Methods With both quantitative and qualitative analysis, medical records made by residents were sampled in groups to study their standardization. Results Recognition rate of such medical records was 82.55%, and the excellence rate was 24. 50% in the grade evaluation. For senior residents, their rate of writing excellence falls below those of junior ones; whether the evaluators have medical background bears no significant difference for grade evaluation of medical records writing, yet a significant difference was found with the recognition rate. Conclusion Writing of medical records by residents is found with incompliance now and then, and the recognition rate ought to be improved.