2256例科间会诊病历统计分析

Statistical Analysis of 2256 Cases of Consultation Among the Medical Departments

目的通过会诊质量监测与管理,分析科间会诊病历存在的问题,探讨提高会诊质量的对策。方法对2256例科间会诊病历进行回顾性分析,就会诊医师资质、会诊原因、会诊目的、会诊意见、病历中会诊意见及执行情况记录、会诊后效果评价记录等因素利用Excel进行分类统计分析。结果全院申请会诊量最大科室为产科,占18.95%,其次为妇科、神经内科、普外科、内分泌科等;会诊原因以出现相应专业症状、体征会诊(占58.91%)最高;会诊医师资质中,主治医师会诊量达1263例,占55.98%;会诊缺陷病历为1410份,占62.5%。讨论应严格执行会诊管理制度及加强会诊管理;完善会诊信息系统等措施,提高会诊质量。

Objective Through monitoring and managing the consultation among the medical departments to analyze the problems of cases about consultation, for exploring how to improve the quality of consultation. Methods A retrospectively analysis was 2256 cases of consultation among the medical departments, will be attending physician qualification of consultation, reasons for consultation, aims, suggestions, effect evaluation of consultation and other factors using Excel statistical analysis to classify. Results The hospital for the largest consultation department for obstetrics, accounting for 18.95%, followed by gynecological, neurological department of internal medicine, general surgery, Endocrinology; reasons for consultation with corresponding professional symptoms and signs consultation（58.91%）. The highest physician consultation qualification and physician consultation quantity of 1263 cases, accounting for 55.98%; consultation of defective medical records of 1410 copies, accounting for 62.5%. Conclusion strict consultation management and consultation information system should be improved to improve the quality of consultation.