病程记录书写存在的缺陷分析

The Analysis of Defects in Writing Progress Notes

目的探讨病程记录书写存在的问题,提高病案的内涵质量,减少医疗纠纷发生。方法按照《广东省病历书写与管理规范》对我院2011年3月至11月内科出院的病案1500份进行终末质控,并对480份病程记录书写有缺陷的病案进行统计分析。结果 480份病程记录书写存在缺陷,其中模仿他人签名150例(31.3%),首次病程记录未在患者入院8h内完成102例(21.3%)。结论客观、真实、准确、及时、完整、规范地书写病程记录,能有效地保护医患双方的合法权益,减少医疗纠纷。

Objective To study the problems existing in the course of writing progress notes, improve the medical record quality and reduce medical disputes. Methods According to Medical Records and Management Practices of Guangdong Province, we did the final quality control with t 500 medical records of the patients who discharged from our department of internal medicine from March to November in 2011 and made statistical analysis of 480 records with defects in progress notes. Results 480 medical records had defects, in which 150 （31.3%） cases were imitating others＇ signature, 102 （21.3%） cases were not completed within 8 hours after admission in the first course record. Conclusions Writing the progress notes objectively, truly, accurately, timely, completely and standardly can not only effectively protect the legal rights of both doctors and patients, but also reduce medical disputes.