聘用医师书写的病历缺陷分析与对策

Analysis of Quality Defects Medical Records Writed by Employee Doctors and Its Countermeasures

目的分析聘用医师病历书写质量现状,探讨管理对策,规避医疗纠纷的发生。方法回顾对聘用医师2013年10月至2014年3月独立完成的1799份终末归档病案质依据《病历书写基本规范》及总部病历评分标准进行质控统计、分析存在的缺陷问题。结果甲级病案1656份,占92.05%;乙级病案143份,占7.94%;无丙级病案出现。存在缺陷病案369份,缺陷项达35项,外科系统明显高于内科系统。结论加强病历书写规范与法律知识的学习,提高聘用医师准入门槛,实行岗前培训与末位淘汰制,用奖惩机制激活聘用医师的内在动力,提高病历书写质量。

Objective To analyze quality status of medical records which were wrote by emplwee doctors and to explore management countermeasures and avoid the occurrence of medical disputes. Methods A total of 1799 copies of terminal archive medical records from October 2013 to March 2014 were examined according to basic norms of medical record writing and headquarters medical record evaluation standard. Results There were 1656 Class-A medical records, accounting for 92.05%; There were 143 Class-B medical records, accounting for 7.94%; There was no Class-C medical record. There were 369 Defect medical records, 35 items defects. The defects of surgical system were significantly higher than internal medicine system. Conclusion We should strengthen the study of medical record writing standards and legal knowledge, improve barriers to entry of the employment, implement pre-service training and lowliest place elimination, activate employee doctors inner motive power by rewards and punishment mechanism, improve the quality of medical record writing.