4800份打印病案常见缺陷分析与改进措施

Common Defects Analysis and Improvements of 4800 Print Medical Records

目的探讨出院电子打印病案的质量缺陷产生的原因,促进病案管理质量的提高。方法随机抽查2009年7月至2010年7月我院打印出院病案4 800份,依据卫生部颁布的《病案书写基本规范》、《电子病历基本规范(试行)》以及《广东省病历书写规范》进行质量评定。结果发现病案首页、术前讨论、手术记录、病程记录、医学影像检查报告、实验室检查结果等出现缺陷,缺漏情况最普遍。结论加强医师法制观念教育,提高病案记录人员的专业水平,制定严格管理制度,加强各环节管理,是确保病案质量的关键。

Objective To study the cause of quality defects of print records and to improve the quality of medical records management.Methods To assess the quality of 4800 random medical records during July 2009 to July 2010 according to basic norms of medical record writing,basic norms of electronic medical records and standardized medical records of Guangdong province.Results There are some defects in the first page of medical records,preoperative discussion,operation record,progress notes,report of medical imaging and laboratory test results.The first page of medical records of different times response the system characteristics of the times through the changes of quantity,content and focus of medical records.It appears frequently in missing items.Conclusion The keys to ensure the quality of medical records are strengthening the legal concept education of physician,improving the professional standards,strict management system and strengthening the management of all sectors.