综合性医院病历质量管理研究

General hospital medical record quality management research

目的:规范病历书写,保证病历质量,提高医疗质量,防范医疗纠纷。方法:从成都市某三甲综合性医院各个临床科室的病历中进行随机抽查500份,并对检查结果进行分析。结果:500份抽查病历中,甲级病历374份,占74.8%;乙级病历117份,占23.4%;丙级病历9份,占1.8%。

Objective To standardize medical writing, quality assurance records, improve medical quality and prevent medical disputes. Methods From General Hospital of the various clinical departments of medical records was conducted by random sampling 500, as well as the results for analysis. Results The medical records of 500 random checks,the first grade medical history be 374 and have 74.8%;The second grade medical history is 117 and have 23.4%;The C grade medical history is 9 and have 1.8%.