4375份病案缺陷原因分析及策略

Analysis on Defect Reasons of 4375 Medical Records and Strategy to it

目的查找病案质量缺陷及产生原因,以寻找改进或提高病案书写质量的策略。方法对4375份住院病案按北京市卫生局《住院病案(终末)书写质量检查表》进行检查及统计分析。结果 4375份出院病案均有缺陷,其中未填写和未记录占39.3%,填写或书写不规范不完整占32.7%,概念或书写错误占28%。结论医师责任心不强、基础知识不扎实及医师结构不合理是导致病案质量不高的主要原因。因此,通过专业培训,强化医师的基本功训练和责任心,加强三级医师责任制,注重病案环节质量的监控,是一项长抓不懈的系统工作,需要全体医务人员共同努力。

Objectives Seeking quality defect of medical records and the causing reasons in order to find out the strategies of perfecting and improving writing quality of medical records.Methods Final medical records are examined and statistically analyzed by Quality Evaluation Standard of Medical Records of Beijing.Results All medical records have one to several defects,such as non-filling and non-record;non-standard and non-complete of filling or writing;wrong concept or writing.Doctors are not master writing standard of medical records,lack of value and responsibility and law concept that are the reasons causing defects of medical records.Conclusions Improving medical records quality through intensifying learning and enhancing responsibility and law concept which is a long-term systematic work needs all medical staff make great efforts together.