689份住院病案中诊断书写缺陷分析和对策

Analysis on Writing Defects of diagnosis in 689 Copies of Hospitalization Medical Records and Countermeasures

目的了解诊断书写质量,有针对性的制定解决对策。方法对689份病案质量检查缺陷中的诊断问题进行回顾性调查分析。结果不规范的诊断问题占检查病案所有问题的14%,有35%的病案存在诊断书写缺陷。结论存在的诊断质量问题重点在书写质量方面。改进主要在于提高医师重视程度,加强上级医师检查和指导,为医师提供规范诊断词库和细化关于诊断书写的要求等。

Objectives This paper researches the writing quality of diagnosis,making out countermeasures with aim.Methods It had a retrospective analysis on diagnosis problems of quality defects in 689 copies of medical records.Results Non-standard diagnosis problems take up 14% of all the problems which 35% of medical records have writing defects of diagnosis.Conclusions The key point of existing diagnosis quality is writing quality.It needs doctors＇ attention degree improvement,superior doctor examination and instruction strengthening and standard diagnosis word stock and the requirement of refining diagnosis writing.