住院病案中诊断书写缺陷的研究分析

An analysis of deficiencies of diagnoses in the medical records of the inpatients department of information

疾病的诊断名称是病案极其重要的一部分,也是住院病案检查的重点。本研究对我院出院病案中关于诊断书写缺陷的问题进行总结,存在的诊断质量问题重点在发现诊断书写缺陷主要有诊断不全面、诊断术语不规范、住院病案中各处诊断书写不一致、最后诊断处空缺等。对发生诊断书写问题的原因进行了分析,提出改进措施主要在于提高医师重视程度,加强上级医师检查和指导,为医师提供规范诊断词库和细化关于诊断书写的要求等。

The name of disease diagnosis is extremely important part of the medical records, but also the focus of hospital medical record checks. In this paper, I have questions about the hospital discharge diagnosis in the medical record written defective summarize, there is a focus on diagnostic quality problems are mainly found in the diagnosis of writing defect diagnosis is not comprehensive, diagnostic terminology is not standardized, inconsistent throughout the hospital medical record in writing the diagnosis, the final diagnosis at vacancies and so on. The key point of existing diagnosis quality is writing quality, It needs doctors＇ attention degree improvement, superior doctor examination and instruction strengthening and standard diagnosis word stock and the requirement of refining diagnosis writing.