病程记录中的“三分析记录”情况分析

Three Analytic Records in Progress Notes

目的了解"三分析记录"书写质量。方法随机抽查出院和死亡病历1301份,对其质量情况进行分析。结果部分病历的"三分析记录"在条理性、针对性、是否符合临床实际、评价是否客观等方面存在较大缺欠。结论突出诊断、用药和疗效分析在病程记录中的重要地位,使病程记录更有针对性,符合临床实际,有助于提醒提高医疗工作效率,提高病历质量。

Objective To understand the writing quality of ＂the three analytic records＂.Methods 1301 case of discharge and death records were randomly selected,then the writing quality of which were analysed.Results A number of the selected case records were found to have problems in terms of organization,adaptability,conformity with clinical practice,and objectivity in evaluation.Conclusion Emphasis on the important place of the ＂three analytic records＂ in the progress notes will make the notes more conform with clinical practice,therefore to improve the writing quality of case records and enhance medical work efficiency.