摘要
目的通过运行病历质量检查，提高病历书写质量。方法对2013年1月～2013年6月运行病历进行环节质量监控，共抽查1200份运行病历，对存在的缺陷汇总分析。结果缺医师签名、病程记录不及时、内涵缺陷、手术风险评估表、安全核查表缺项、各类同意书填写不全缺陷占常见缺陷85．1％。结论运行病历质控是现场检查，发现病历缺陷并及时改正，可保证终末病案质量。
Objective Through quality check of running medical records to improve the quality of medical records. Method From January 2013 to June 2013 implement process quality control of running medical records, with a total collection of 1200 samples, and summarized the presented quality defects. Result Missing physician signature, the course record is not timely, the defects of connotation, missing items in surgical risk assessment form and safety c, hecklists, and all kinds of incomplete defect in filling consents represent 85.1% of the common pitfalls. Conclusion Run medical quality control is on - site inspections, and promptly correct the deficiencies found in the medical records, so the quality of the terminal medical records will be ensured.
出处
《现代医院》
2014年第2期105-106,共2页
Modern Hospitals
关键词
运行病历
缺陷
分析
改进
Running medical records, Quality defects, Analysis, Improvement
