6433份终末病案的质量分析及对策

Quality Analysis and Countermeasures of 6433 Terminal Medical Record

目的寻找终末病案缺陷原因以改进病案质量。方法对2011年1月-6月6433份病案进行质量检查并作统计分析。结果病案首页填写缺陷823处,占缺陷病案数的12.79%;病程记录缺陷901处,占缺陷病案数的14.01%。上级医师签字不及时705处。医师重视程度不够、基本功欠扎实、有些科室临床三级医师梯队不健全、医务人员工作量大等因素是造成病案缺陷的主要原因。结论应从加强医师的教育培训,强化医师的基本功训练和责任心,认真执行三级医师责任制,注重病案环节从质控方面入手提高病案质量。

Objective To look for a terminal medical record defects reasons and to improve the quality of medical records. Methods 6433 medical records were checked and analyzed from Jan 2011 to Jun 2011. Results There are 823 defects of the front sheet of medical records, accounting for 12. 79%. There are 901 defects of progress records, accounting for 14.01%. There are 705 defects of superior doctor signature not in time. Lack of the attention of doctors, basic skills are not solid, clinical 3 - level doctors echelon unsound, heavy workload of medical staff are the main reason for the medical record defects. Conclusion We should strengthen the education and training, strengthen basic skills training and responsibility, faithfully imple- ment 3 - level physicians responsibility system, focus on the medical record links to improve the quality of medical records.