393例死亡病案基础质量监控与缺陷分析

Quality Monitoring and Defects Analysis of 393 Medical Records of Death

目的分析死亡病案基础质量中存在的问题,提高死亡病案书写质量。方法对某医院2013年393例死亡病案抢救记录、死亡记录及死亡病例讨论、尸检知情同意书的签署等完成情况进行回顾性分析。结果死亡病案基础质量存在的问题:死亡时间填写错误(52.8%);抢救医务人员姓名及专业技术职称记录书写不规范(22.0%);无尸检知情告知(18.0%);超时限完成病案书写(7.3%)。结论医院可通过加强职业道德培训、病案书写培训、利用信息技术以及完善质控结果反馈来加强死亡病案的基础质量控制。

Objective To analyze the problem of basic quality in medical records of death to improve the quality of them. Methods 393 medical records of death in a hospital in 2013 were retrospectively analyzed from rescue records,death records,death cases discussion and the signing of the informed consent of autopsy. Results The defects were mainly four aspects：Filling in the wrong time of death（52.8%）, the rescue staff name and technical titles written is not standard（22.0%）, the absence of the informed consent of autopsy（18.0%） and beyond limit time（7.3%）. Conclusion Strengthening professional ethics training and medical record writing training,making full use of information technology and problems of feedback can improve the quality of medical records.