摘要
目的通过住院病案的缺陷分析,制定对策,提高病案质量。方法以病案书写规范为标准,针对2706份缺陷病案进行分析,总结缺陷原因。结果 2706份缺陷病案存在6大方面31项缺陷。结论应从加强医师的教育培训、认真执行三级医师责任制和加强监管三方面入手提高病案质量。
Objective To improve the quality of medical records by analyzing defect.Methods Analyzing 2706 defective medical records and finding causes of defectives according to medical record writing standard.Results There were six major aspects of 31 defects.To develop corrective measures for the defects.Conclusion There are still some defects in medical record.We should enhance education and training,implement three grades physician responsibility and strengthen supervision.
出处
《中国病案》
2011年第8期15-16,共2页
Chinese Medical Record
关键词
缺陷病案
分析
对策
Defective medical record
Analysis
Countermeasures
