死亡病案质量缺陷分析及对策

The Analysis and Countermeasure of Quality Defect in the Medical Records of Death

目的了解厦门某三甲医院死亡病案书写质量,针对所发现的问题提出对策,以提高死亡病案书写质量。方法组织院内专家对本院2013年111例死亡病案进行质量检查,统计每份死亡病案缺陷所在,并进行原因分析。结果 (1)普通缺陷,前三项依次是病程记录、入院记录、病案首页。(2)内科系统与外科系统平均每份死亡病案缺陷数分别为(4.72±0.16),(5.59±0.20)(Z=-2.995,P=0.003),提示内科系统死亡病案质量优于外科系统。结论完善相关制度建设、建立严格的奖惩制度、加强人员培训等,从而有效避免死亡病案缺陷。

Objective In order to understand the quality defects existing in medical records of death in one of the hospital in Xiamen,and put forward some measures for improvement. Methods 111 medical records of death from January 2013 to December 2013,were examined by the experts in our hospital,and the defects were analyzed to seek countermeasures.Results（1）Three of the common defects,were Medical record,Hospital Admissions record and the Home of Medical record.（2）The average quality defects of death medical records in department of internal medicine system and surgery were （4.72±0.16）,（5.59±0.20）,（Z=-2.995,P=0.003）,which suggests the quality in medical records of death in department of internal was better than that of surgery.Conclusion Improving the relevant systems,establishing reward,punishment system,may reduce quality defects in the death medical record.