摘要
目的回顾急诊科死亡档案现状规范急诊死亡病案的管理。方法调取2011年1月至2013年11月在我院急诊死亡的1383例急诊病案,并从建章立制、明晰职责、及时沟通、持续改进、各尽其责等方面进行回顾性分析。结果 1373份病案及时回到挂号室的库中,另有10份通过查找被及时追回。1383例急诊死亡病案无一例丢失。结论通过对急诊死亡病案的专项工作管理,提高了护理人员的法律意识以及责任意识,同时保证病案保存内容完整和对此项管理更加规范,使病案价值得到最大实现。
Objective To make the specification of emergency death medical record management by reviewing the emergency death medical record. Methods A total of 1383 emergency medical records in our hospital from January 2011 to November 2011 were retrospectively analyzed from building rules and regulations, clear responsibilities, timely communication, continuous improvement, take responsibility and so on. Results There are 1373 medical records timely return to medical record room. Another 10 copies of medical record was recovered in time by looking up. There is no loss of 1383 emergency medical records. Conclusion We improve the nurses' legal consciousness and responsibility consciousness through the special work management of the emergency death medical record, at the same time ensure that the medical record content intact and death medical record management more standard, and make medical record get the biggest value.
出处
《中国病案》
2014年第8期18-19,共2页
Chinese Medical Record
关键词
死亡病案
专项管理
持续改进
Death medical record
Special management
Continuous improvement