2009年我院病历档案质量统计分析

The Quality Control Of Medical Record

目的对病历档案中存在的问题进行统计分析以进一步提高病历质量。方法参照相关标准对我院2009年的所有出院病历进行质检。结果甲级病案率为99.5%,乙级病案率为0.5%,无丙级病历;全院病历档案总合格率为97.2%,病历差错以首页缺陷为主,占66.1%。结论通过强化病历书写规范化培训,强调病历档案质量的重要性等措施可以有效的提高病历档案质量。

Objective To improve the quality of medical records through analyzing on the problems of medical record. Methods All the case history of patients who had hospitalized in the year of 2009 were checked referring to relevant standards. Results The rate of the record Class A is 99.5%, that Class B is 0.5%, and non records was Class C. The total eligible rate of md medical record was 97.2%.Most of the medical record errors were the first page mistakes, the proportion was 66.1%.Conclusion It can effectively improve the quality of medical records by Strengthening Standardized Training on writing of medical record and emphasizing the importance on quality.