某三甲医院住院病历满页打印现状分析

Status of inpatient medical record full page print in a tertiary hospital

目的:通过对某三级甲等综合医院住院病历满页打印现状进行分析,发现问题,进而提高病历质量。方法:对26个临床科室的127次查房随机抽取的384份病历,运用SPSS11.5统计软件包进行统计分析。结果:住院病历满页打印总体的及时率较高,但外科各科室满页打印率较低。结论:医务人员要重视及时满页打印,应加强监督并建立激励机制,以提高病历质量。

Objectives： By analyzing the status of full page print of inpatient medical records in a tertiary hospital to find problems and improve medical record quality.Methods： 26 clinical departments of the 127 rounds in a random sample of 384 copies of medical records were selected and SPSS11.5 software was used to analyze the data.Results： The overall rate of inpatient medical record timely full page print is relatively high but surgery departments are relatively lower.Conclusions： The medical staff should pay attention to timely full page print.Supervision and incentive mechanism is needed to improve medical quality.