住院病案会诊记录缺陷与对策探讨

Discussion on Defects and Countermeasures of Consultation Records of Inpatient Medical Records

目的分析探讨住院病案会诊记录缺陷与对策。方法以福建省宁德市医院2019年5月1日-2019年5月31日间出院的1 380份住院病案为研究对象,对会诊记录的相关内容进行质量检查,并计算出现质量问题的会诊记录在所有病案中的占比情况。结果在会诊纪录的书写中,医师资质未记录,会诊时间不明确,会诊结果有缺陷,体格检查不全面且记录缺少重要内容,会诊意见与会诊目的不一致,以上六者占比差异均具有统计学意义(P<0.05)。结论医院的会诊记录存在记录不规范情况,需要加强病历书写的质控力度,加大对医护人员的培训力度,灵活运用互联网技术与信息技术,减少会诊记录的缺陷,提高医护人员的会诊记录书写水平,提高病历书写质量。

Objective To analyze and discuss the deficiencies and countermeasures of inpatient consultation records.Methods Through taking 1 380 inpatient medical records discharged from the hospital from May 1,2019 to May 31,2019 as the research object, the quality of consultation records was checked, and the proportion of consultation records with quality problems in all medical records was calculated. Results In the writing of consultation records, the qualifications of doctors were not recorded,the consultation time was not clear, the consultation results were defective, the physical examination was not comprehensive and the records lacked important contents, and the consultation opinions were inconsistent with the purpose of consultation. The differences of the six percentages were statistically significant(P<0.05). Conclusion The hospital consultation records are not standardized. It is necessary to strengthen the quality control of medical record writing, strengthen the training of medical staff, flexibly use Internet technology and information technology, reduce the deficiencies of consultation records, improve the writing level of medical staff consultation records, and improve the quality of medical record writing.