重庆市乡镇卫生院病案书写质量调查

A Survey of Medical Record Writing Quality of Township Hospitals in Chongqing

目的加强和规范乡镇(中心)卫生院病案书写质量,提高医疗技术水平。方法随机抽查34所乡镇(中心)卫生院出院病案共340份,按2010年卫生部《病历书写基本规范》内容对照检查。结果病案书写缺陷率较高,其中病程记录缺陷率达63.53%、手术记录缺陷率40.88%。结论应加强乡镇(中心)卫生院院、科、室三级病案质量管理体系建设,提高病历书写质量管理,确保医疗安全和医疗质量。

Objective To strengthen and standardize the quality of writing of the township hospitals medical records and raise the level of medical technology.Methods A random check of 340medical records from 34 towns（central） hospitals and the records were checked according to the basic norms of medical records of 2010.Results There is a higher defect rate of medical record writing and the defect rate of progress notes is 65.53% and the defect rate of operation records is 40.88%.Conclusion The construction of record quality management system of hospital,scientific and room should strengthened,the quality of records＇ writing should be improved,and to ensure medical safety and quality of care.