407例死亡病案首页书写质量分析

Quality Analysis on the Home Pages Writing of 407 Cases of Death Medical Records

目的了解死亡终末病案首页书写质量,分析书写存在的缺陷,探讨提高死亡病历书写质量的有效方法。方法抽取2014年407份死亡病案首页进行缺陷分析,选择6项内容作为评价项目。结果 407份病案首页的主要诊断选择完全正确的318份,占78.13%,其他诊断书写正确314份,占77.15%,入院病情书写正确的329份,80.84%,主要手术书写正确的142份,占手术病历83.04%。结论主要诊断选择错误是影响病案首页书写质量的重要问题,应对临床医师进行管理和培训,以保证医疗质量、确保医疗安全,主要诊断选择是准确绩效评价的前提。

Objective To understand the writing quality home pages in terminal death medical record, analyze the defects and explore effective methods to improve the writing quality of medical records. Methods 407 cases of home pages in death medical records in 2014 were selected to conduct defects analysis, 6 items were chosen for evaluation. Results 318 （78.13%） primary diagnosis in home pages was completely correct in 407 death medical records, 314（77.15%） other diagnosis writing were correct, 329 （80. 84%） admission condition writing were correct, 142 main operation writing were correct, which accounting for 83.04% of surgical medical records. Conclusions The mistaken selection of main diagnosis was the important problems that affected the writing quality of medical record, we should strengthen the management and training of the clinical doctors so as to ensure the quality and security of medical treatment, which is the premise of accurate performance evaluation.