多种措施提高门诊病历书写质量

Measures to improve the outpatient medical record.

目的了解门诊病历书写情况，分析扣分原因，提出改进方法。方法抽查中国医学科学院肿瘤医院2014年4月至2015年4月期间的门诊病历，每个工作日抽取出诊的每位门诊医生的5份病历，每月按序抽取3个工作日，进行评定。结果11954份门诊病历中，合格病历（评分≥95分）4891份（占40．92％）；对扣分病历内容进行分析，门诊病历扣分情况归类为11类。针对扣分情况，医院采取相应的措施。历时5个月后，书写合格的门诊病历份数提高。2015年10月至2015年12月抽查的2627份门诊病历中，合格病历2115份（占80．51％）。结论通过有效措施，书写合格的门诊病历增长了39．59％，提高了门诊病历的书写质量。

Objective To learn the current situation of outpatient medical records and reasons why they are unquali- fied and offer suggestions for improvement. Methods From April 2014 to April 2015, fiveinitial patient doctor＇s assessment records from every outpatient doctor were collected. Monthly, three days were randomly selected and analyzed. Results In 11 954 outpatient records, the up-to-standardrate （score of 95 points or more） was 40.92% （4891/11954）. There are 11 types of defects in the unqualified medical records. We used multiple interventions to improve the quality of outpatient records. Five months later, the number of qualified records increased. From Oct. 2015 to Dec. 2015, in 2 627 cases of out- patient medical records, the up-to-standard rate increased to 80.51% （2115/2627）. Conclusion Through effective actions, the number of qualified record increased by 39.59%.