普通门诊病历质量及其不合格原因分析

The quality of general out-patient medical records and the unqualified reasons

目的 了解临床医师普通门诊首诊及复诊病历合格率,分析不合格原因,提出改进建议.方法 收集首都医科大学附属北京朝阳医院心内科2013年7月8日～7月12日门诊病历,每天随机抽查门诊接诊医师书写的门诊首诊病历10份,连续5天共50份,并一对一追踪其复诊病历.同期计算门诊全天接诊患者总数及接诊医师人数,并记录书写一份合格普通门诊病历的时间.结果 普通门诊首诊病历合格率44.0％,复诊病历合格率45.7％.首诊病历不合格的主要原因为缺项,复诊病历不合格的主要原因为缺乏对首诊治疗或诊断的反馈性记录.连续5天患者的就诊人数平均为（812±85）人次/天,接诊医师平均每天接诊145例患者,每3.3分钟接诊1例患者.合格首诊病历和复诊病历的书写时间分别为（11.7±1.2）分钟和（10.7±1.2）分钟,8小时能够接诊48位患者,实际接诊145位患者,超出2倍多.结论 普通门诊首诊和复诊病历合格率较低,加强针对门诊病历书写的继续教育非常重要.需要引起重视的是普通门诊患者流量太大,应当科学合理地制定单位时间内患者流量,确保医疗质量,努力营造医患和谐、共享尊严的医疗环境.

Objective To understand the up-to-standard rate of initial and follow-up medical records among clinicians in general out-patient,and to analyze the unqualified reasons and suggestions for improvement.Methods From July 8,2013 to July 12,2013,collect ten of initial out-patient medical records daily randomly in the Heart Center of Chaoyang Hospital of Capital Medical University,on 5 consecutive days,a total of 50,and one to one track their referral records.Over the same period,calculating the total number of out-patient patients and doctors in the whole day,and recording the time of writing a qualified general out-patient medical record.Results The up-to-standard rate of the first outpatient medical records is 44.0% and the follow-up records is 45.7%,the main reason of the unqualified initial records is missing items,the main reason of the unqualified follow-up records is lack of feedback records about the initial treatment or diagnosis.For 5 days the number of patients with an average of （812＆#177; 85） per day,the number of patients＆#39; admission by one doctor is 145 on average per day,one patient received 3.3 minutes.The time of writing a qualified initial medical records and follow-up records were respectively（11.7＆#177;1.2） minutes and （10.7＆#177;1.2） minutes,48 patients should be treated in 8 hours,but the actual admissions is 145,which is 3.02 times of the theory number of admissions.Conclusions The up-to-standard rate of initial and follow-up medical records is low,and it is important to strengthen the continuing medical education about paying full attention to writing medical records; It is worthy to note that the general outpatients flow is too large,we should develop the number of patients per unit time reasonably,to ensure the quality of medical treatment,and create a harmonious relationship between doctors and patients,sharing the dignity of medical environment.