746份终末病案上级医师查房记录的质量分析

Quality Analysis of Superior Doctors Ward Round Records of 746 Terminal Medical Records

目的通过对我院终末病案上级医师查房记录进行质量分析,以提高病历书写质量和临床诊疗水平。方法回顾性分析我院2011年1月至2012年7月746份终末病案上级医师的查房记录,查找所存在的缺陷和不足。结果上级医师查房记录中主要存在的问题包括:(1)上级医师查房记录时间不按时;(2)查房医师的姓名和专业技术职务记录不完全;(3)对患者病史、症状和体征的补充记录不完整;(4)对诊断依据及鉴别诊断缺乏分析;(5)记录中套话较多,无实质性指导意义。结论上级医师查房记录中存在的问题涉及多种原因,应采取针对性的综合有效措施才能不断提高病历书写质量。

Objective To analyze the quality of superior doctors ward round records of terminal medical records and improve the quality of medical record writing and clinical diagnosis and treatment level. Methods Analyze superior doctors Ward round records of 746 Terminal medical records between January 2011 and July 2012 and find the defects and deficiencies. Results Major problems in- dude： （1）Superior doctors ward round record is not on time; （2）The name and professional and technical posts record is not com- plete; （3）Addition record of medical history, symptoms and signs is not complete; （4） Lack of diagnosis basis and differential diagno- sis analysis; （5）Empty conventional talk with no substantive significance. Conclusion Problems of superior doctors ward round records involved in a variety of reasons. Corresponding comprehensive effective measures should be taken to continuously improve the quality of medical record writing.