门诊病历书写质量的调查分析

Analysis on Investigation of Writing Quality of Outpatient Case Records

目的了解目前门诊病历存在的问题,探讨加强质量管理的措施。方法拟定《门诊病历书写质量评分标准》,回顾性评价广西地区6家三级医院门诊病历1000份,了解主要质量问题,统计合格率和7大项被扣分率。结果门诊病历主要缺陷种类多,合格率仅44.20%;电子打印病历合格率比传统手写病历合格率高(P<0.001);病史(49.60%)、体检(38.70%)和医师签名(36.70%)被扣分率较高。结论目前门诊病历书写质量低,缺陷种类多,缺乏有效监管是合格率低的根本原因,迫切需要加强管理。

With the purpose of understanding the existing problems in outpatient medical records and exploring the measures for strengthening quality management, the authors evaluate in retrospect 1,000 medical records in 6 hospitals of third grades in Guangxi, learn about the main problems of quality, and the passing rate of statistics and the deduction rate in 7 items with the formulated Marking Criteria for the Writing Quality of Outpatient Medical Records. The result shows that there are diversified defects in outpatient medical records, the passing rate is only 44. 20%, the passing rate of electronically printed medical records is higher than that of hand written ones （P 〈 0. 001 ）, the deduction rate in medical history （49. 60% ）,physical examination （38. 70% ） and doctor signature （36. 70% ） is rather high. The conclusion is that the quality of medical record writing is low, the kinds of defects are many, and the basic reason for the low passing rate results from the inefficient supervision and management, which needs enhanced management badly.