口腔颌面外科住院病案质量存在的问题及思考

Problems and Reflection of Inpatient Medical Record Quality in Oral and Maxillofacial Surgery

目的通过抽查医院口腔颌面外科住院病案,分析病案质量存在的问题,并提出针对性的改善病案质量管理的对策,以期改进口腔颌面外科住院病案质量。方法抽查了2013-2014年间口腔颌面外科住院且归档的病案500份,对病案质量存在的问题进行汇总分析,并深入剖析存在问题的原因以及改进病案质量的建议。结果口腔颌面外科住院病案书写中主要存在以下问题:记录不及时、内容不相关或不详细、缺项、病史缺乏系统性和科学性、病程记录缺乏针对性、出院原因界定不清、无签名等。结论口腔颌面外科住院病案质量存在一定的问题,可以通过提高病案书写能力,强化病案质量意识、加强管控、改善和落实制度等进行改进。

Objective By randomly checking inpatient medical record in oral and maxillofacial surgery and analyzing the existing quality problems in medical record, put forward corresponding countermeasures for medical record quality management so as to improve inpatient medical record in oral and maxillofacial surgery. Methods 500 cases of inpatient medical records in oral and maxillofacial surgery from 2013-2014 were checked and the problems in medical record quality and their causes were analyzed before relevant suggestions were put forward. Results The main problems of inpatient medical records in oral and maxillofacial surgery included： delayed record, unrelated or undetailed content, deficiency, the lack of systematic and scientific medical history, the lack of pertinence, indistinct definition for discharge and the lack of signature. Conclusion Inpatient medical record in oral and maxillofacial surgery has certain problems, which could be improved through improving medical record writing ability, strengthening medical record quality consciousness, strengthening control, improving and implementing relevant policies.