摘要
目的通过儿科门诊病案记录缺陷分析,制定改进措施,提高病案质量。方法以卫生部《病历书写基本规范》为标准,对7200份儿科门诊病案进行质量检查,应用SPSS17.0统计软件进行缺陷数据统计分析。结果 1224份儿科门诊病案存在缺陷,共出现缺陷次数1540次,缺陷数据进行卡方检验,P<0.01,差异具有显著性。结论通过提高思想认识、强化学习培训、加强质量监控、减轻工作强度提高儿科门诊病案质量。
Objective to make reform plans and improve the quality of medical records through the analysis of medical records of pediatric clinic. Methods As the standard of Basic Norms of Medical Records Wring of department of health, 7200 copies of pediatric clinic medical records are exam- ined by using SPSS 17.0 statistic software to analyze defects data. Results There are 1,540 defects in 1,224 medical records of pediatric clinic. Chi- square test is done on the defective figures, P 〈 0.01. The difference is obvious. Conclusions We should improve the quality of medical records of pedi- atric clinic through the methods of enhancing ideological understanding, reinforcing training, strengthening quality supervisory control and reducing the intensity of work.
出处
《中国病案》
2012年第3期26-26,M0002,共2页
Chinese Medical Record
关键词
儿科
病案
缺陷
隐患
分析
Pediatrics
Medical records
Defect, potential risk
Analysis
