1104份终末病历缺陷分析与对策

An Analysis on the Defects of 1104 Cases of Terminal Medical Records and Relevant Countermeasures

目的探讨病历缺陷对终末病历质控的影响与改进措施。方法根据病历书写基本规范和《南京军区病历质量考核评价标准》,对随机检查的1104份出院病历进行查核,并进行统计分析,研究病案缺陷的项目分布和原因,提出改进完善的方法措施,有效控制和提高终末病历质量。结果随机抽查终末病1104份,缺陷的病历623份(1156处),占56.43%。常见病历缺陷主要是有医嘱缺检查报告单128处,占12.18%、漏填或填错药物过敏126处,占11.99%、局部拷贝、错别(漏)字、病句65处,占6.18%、缺有创诊疗操作记录44处,占4.19%、辅助检查报告医生未签名41处、占3.90%。结论根据病历缺陷的类型和原因采取积极改进措施,可以消除病案缺陷,大大提高病案的质量。

Objective To explore the influence of defects on the quality control of terminal medical records and relevant improving countermeasures. Methods To conduct an examination on 1104 cases of discharge medical records selected from our hospital randomly according to the basic writing guide lines of medical records and the ＂Evaluating Standard of Medical Records Quality of Nanjing Military District＂. Then a statistical analysis was performed to research the distribution and reasons of the medical records defects, and put forward improvement countermeasures to control and improve the quality of terminal medical records effectively. Results There were 623 cases and 1156 items mistakes in the 1104 cases of medical records inspected, which occtipied 56%. The common defects mainly included many aspects such as without examination report for 128 cases of doctors＇ advice, which accounted for 12. 18% ; 126 places of missing or mistaken filling of drug allergy, which accounted for 11.99%; 65 places of local copy, wrong or missing words and wrong sentences, which accounted for 6. 18% ; 44 places of lacking invasive diagnosis and treatment records, which accounted for 4. 19% ; and without signatures of doctors on the examination reports, which accounted for 3.9%. Conclusions Taking active improving measures according to the types and reasons of medical records defects could eliminate the defects and promote the quality of medical records greatly.