新疆某院2124份诊断证明书的书写质量分析

Writing Quality Analysis on 2124 Cases of Certificate of Diagnosis in a Xinjiang Hospital

目的了解某医联体医院诊断证明书的书写质量状况,提高书写质量,改善患者就医体验。方法本研究根据某院门诊部2016年7月-2016年12月质控检查记录,对27个科室2124份诊断证明检查记录结果进行分析。结果 27个科室中产科、妇科、骨科、眼科和急诊科开具诊断证明书超出100份,2124份诊断证明书中有493份不合格,不合格率为23.21%,妇科不合格率最低为4.00%。不合格原因以患者职别及住院/门诊编号未书写占比最多,分别为44.62%和34.08%,其中有436份患者断证明书一次性盖章不成功,以未书写就诊日期及医师未亲笔签名占比最多,患者不满意有25份,其中引起争执的19份,投诉6份。结论根据分析结果采取改进诊断证明书格式,提供正确的诊断证明书填写标准模板,加强诊断证明书书写规范化培训,质量情况纳入质量考核指标中等措施,规范诊断证明书的书写,保证书写准确无误,提高患者诊断证明书盖章成功率,改善患者就医体验。

Objectives To understand the writing quality of the certificate of diagnosis in a hospital of medical couplet, so as to improve the writing quality and the treatment experience of patients. Methods According to the quality control inspection records of hospital outpatient department from July 2016 to December 2016, the results of 27 inspection records in 27 departments were analyzed. Results The diagnosis certificates were more than 100 in 27 departments included obstetrics and gynecology, orthopedic, ophthalmology and emergency department. The minimum defective rate of department of gynaecology was 4.00%, there were 493 unqualified cases in 2124 copies,the unqualified rate was 23.21%. The unqualified reason to patient＇s job title and in the hospital/clinic number accounted for not writing than most, 44.62% and 34.08%, respectively, in which 436 patients with a certificate of broken disposable seal was not successful, in order to not writing clinic date and physicians not autograph accounted for most, patients were not satisfied with 25 copies, among them 19 cause offense, complaints 6 copies.Conclusions To improve the diagnosis certificate format according to the analysis results, provide the correct diagnosis certificate to fill in the standard template, strengthen written certificate of diagnosis standardization training, into the quality evaluation index, standard certificate of diagnosis of writing, written guarantee accurate,improve the success rate of the diagnosis certificate stamped, improving patient treatment experience.