560份精神科终末病案缺陷分析及对策

Defect Analysis and Countermeasures of 560 Terminally Medical Records of Psychiatry Department

目的探讨精神科病历书写中存在的主要缺陷,分析原因,提出对策,加强病案质量管理,减少医疗纠纷。方法按照《住院病案质量评分标准》,对2013年11月-2014年11月560份出院病案进行终末质量控制,并对缺陷项目进行统计。结果终末病案质控中发现精神科病案存在不同程度的缺陷,以病程记录缺陷最多,占40.9%。结论加强相关法律法规的培训,规范病案书写质量管理,加强基础质量及环节质量管理,完善奖惩制度实施绩效考核是有效避免或降低医疗风险的关键。

Objective To explore main defects existing in the psychiatric medical record writing, and analyze the causes, propose solutions, improve the quality of medical records management, reduce medical disputes. Methods According to Hospital medical records quality criteria,560 terminal medical records were carried out quality control from November 2013 to November 2014. Results We found different levels of defects in psychiatric medical records after Terminal medical record quality control. The course record has the most defects, accounting for 40.9%.Conclusions Strengthen the training of relevant laws and regulations, Standardize quality management of medical records, strengthen basic quality and the link quality management, improve the system of rewards and punishments to implement performance appraisal, are the keys to effectively avoid or reduce the medical risk.