发生医院感染的病历质量问题与对策

Problems and Solutions of the Quality of Medical Records on Nosocomial Infection

目的了解发生医院感染病历质量存在的主要问题,探讨提高病历质量办法。方法根据《病历书写基本规范》、《医院感染诊断标准》等相关制度要求,制定发生医院感染病历质量控制标准,对960份发生医院感染病历进行检查。结果病历书写医院感染内容普遍不完整、不规范。缺陷率较高的前五项分别为未进行相应病原学检查,缺陷率46.46%;手术前讨论(或小结)未提及医院感染,缺陷率45.10%;特异性检查提示有医院感染情况,有治疗医嘱,病程记录无分析、无诊断,缺陷率32.08%;医嘱中围手术期用药不规范缺陷率25.83%;病程记录对医院感染症状、体征描述不规范缺陷率25.00%。结论加强医师医院感染知识培训,提高认识,规范病历中医院感染内容的书写,并开展发生医院感染病历专项质控,能促进病历质量持续改进,提高医院感染管理水平。

Objective To learn the quality problems in nosocomial infection, and to investigate the methods to improve the quality of medical records.Methods According to the requirement of Basic Norms of Medical Records and Diagnostic Criteria of Nosocomial Infection,the quality control standards about nosocomial infection medical records was draw up,and 960 mendical records of nosocomial infection were investigated.Results The writing of mendical records of nosocomial infection is incomplete and not standardized. The top five defect rate are as follows.Not inspecting the corresponding pathogenic accounts 46.46%,not mention nosocomial infection during discussion before surgery accounts 45.10%,no analysis no diagnosis in progress notes accounts 32.08%,Perioperative irregular drugs in prescription accounts 25.83%,irregular description of symptoms and signs about nosocomial infection in progress notes accounts 25.00%.Conclusion The quality of medical records can be improved continuously,and the management on nosocomial infection can be raised by strengthening the training of physician knowledge of nosocomial infection,raising awareness,and standardizing the writing of mendical records on nosocomial infection.