转科记录书写缺陷分析与对策

Defect Analysis on Transferred Record and Its Countermeasures

目的抽查出院病案转科记录书写缺陷类型,分析原因,提出对策。方法依据原卫生部《病历书写基本规范(2010年版)》《军队医院病历书写与管理规则(2010年版)》《电子病案基本规范(试行)》及军区医院病案质量评分标准的细则,抽查出院病案的转科记录书写质量。结果抽检1639份出院病案中转科记录书写的情况,存在缺陷病案263份(263/1639)占16.05%。质量缺陷项目分为22类,共计书写质量缺陷881频次,其中转出记录书写缺陷项目12类,检出缺陷482频次,占总缺陷频次54.71%;转入记录书写缺陷项目10类,检出缺陷399频次,占总缺陷频次45.29%。内科检出书写缺陷379频次(379/881)占总缺陷频次的43%;外科502频次(502/881)占总缺陷频次的57%,转科记录书写质量缺陷外科系统高于内科系统。结论转科记录书写质量与临床医师能力素质、法律意识、责任心、工作态度密切相关。严格岗前培训、强化法律与质量意识、修炼临床基本功、端正工作态度与加大奖惩机制,是提高转科记录书写质量的有效途径。

Objective To spot check transferred record writing defect types, and analyzed the reasons, and put forward countermeasures. Methods On the basis of the former ministry of health of the medical record writing basic specification（2010 edition）, the army hospital medical record writing and management rules（2010 edition）, the basic rules of electronic medical record（try out） and the details of the military hospital medical record quality criteria, sampling 1639 discharged medical record transferred record writing situation. There are 263 defect transferred records, Accounted for 16.05%（263/1639）. Results In 263 transferred record, the quality defects project is divided into 22 classes, a total of 881 frequency of writing quality defects; Including 12 class transfer out record with 482 frequency, accounting for 54.71% of the total defect frequency; Records with transfer into 10 classes, 399 frequency detection defects, accounting for 45.29% of the total defect frequency; internal defects of 881 frequency（379/881） accounted for 43% of the total defect frequency; Surgical 502 frequency（502/881）accounted for 57% of the total defect frequency. Transferred record writing quality defect surgery is higher than the internal medicine. Conclusion transferred record writing quality and clinician＇s ability quality, legal consciousness,the sense of responsibility, work attitude are closely related. Only strict pre-job training, strengthen the awareness of law and the quality, uniting the clinical basic skills, the work attitude, and increase the rewards and punishment mechanism, are the effective ways to improve the quality of transferred record writing.