二胎政策下产科病历书写质量分析及管理对策

Writing Quality of Medical Records in the Obstetrics Department under the Two-Child Policy and the Management Strategy

目的比较二胎政策实施前后产科病历书写质量变化情况,探讨二胎政策下提高产科病历书写质量的管理对策。方法收集某院2013年-2016年产科病历书写质量数据,进行回顾性描述分析。结果二胎政策实施后,该院产科病历书写缺陷率由0.74%提高为0.94%,围手术期记录缺陷与首页缺陷均明显增加。结论医院应把好科室自查关,落实病历环节质控,促进产科病历书写质量和医疗服务质量双提高。

Objective To compare the writing quality of medical records in the Obstetrics Department before and after the implementation of the two child policy, and to explore management measures to improve the writing quality of medical records under the two--child policy. Methods Data of the writing quality of medical records in the Obstetrical Department in a hospital from 2013 to 2016 was collected for retrospective descriptive analysis. Results After the implementation of the two--child policy, the medical records writing defect rate increased from 0.74% to 0.94%, with apparent increase on the writing defect of perioperative record and the home page record. Conclusion Hospital should carry out department＇s self inspection, implement link quality control of medical records, promote the improvement of both the writing quality of medical records and the medical service quality in the obstetrics department.