终末病案医技检查报告单质量缺陷分析与对策

Quality Defects Analysis and Countermeasures of Medical Technology Report of Terminal Medical Record

目的通过对终末病案医技报告单书写缺陷进行统计分析并提出对策,为病案质量控制与医疗安全提供依据。方法依据《病案书写基本规范》要求,对某院2013年9月-2014年3月1369份归档病案中医技报告单书写质量缺陷进行统计分析,找出存在问题。结果 19369份医技检查报告单,其中合格报告单18033份,质量缺陷1336份(占6.9%);尤其是报告单书写不规范或误写115份(8.61%)、或检验检测报告人未签名106份(7.93%);或检验检测报告人及审核人均不签名36份(2.70%);或报告单由无资质人员签发29份(2.17%);报告人签名潦草难以辨认者59份(4.42%);或仿签名检查报告单他人仿签名39份(2.92%);或实验室诊断报告单非检验人员出具76份(5.69%);漏填或错填病案号、姓名、床号现象严重。结论医技人员责任心缺失,法规观念不强,基本知识不扎实、素质不高是只要原因。通过岗位培训,加强继续医学教育,提高医技人员法律意识与业务素养,奖惩并举,规范完善报告单书写质量是医院管理者的当务之急。

Objective Medical technology reports of terminal medical record were analyzed and put forward countermeasures, and provide the basis for medical record quality control and medical safety. Methods Analyzing 1369 copies of medical technology reports from September 2013 to March 2014 according to ＂basic norms of medical record writing＂ requirement, and find out problems. Results There are 18033 qualified reports, 1336 （6. 9%） defect reports in 19369 medical examination report. Especially irregularities or miswriting 115 （8.61%）, or reporter unsigned 106 （7. 93%）, or reporter and reviewer unsigned 36（2. 70%）, or issued by a non-qualified personnel 29 （2. 17%）, or difficult to identify signature 59 （4. 42%）, or copy the signature 39 （2. 92%）, or laboratory diagnostic report issued by non-inspectors 76 （5.69%）. The phenomenons of miss or wrongly filled medical record number, name, bed number are serious. Conclusion Technician lack the sense of responsibility, the concept of law is not strong, the basic knowledge is not sohd, are the main reasons. Through job training, strengthen continuing medical education and improve the legal awareness and Business literacy of medical technician, rewards and punishments simultaneously to standardize and improve the quality of reports are urgent affairs for hospital managers.