病历书写质量在防范医疗纠纷中的作用

The Role of Medical Record Writing Quality in Preventing Medical Disputes

目的分析病历书写质量在防范医疗纠纷中的作用。方法在2019年10月—2020年10月期间收集132例患者,随机抽取,分为两组,研究组66例,用病历书写管理,对照组66例,未用病历书写管理,比较两组的纠纷率、差错率、投诉率、病历书写质量,并评价两组病历缺陷发生率和满意度。结果与对照组进行比较,研究组纠纷率、差错率、投诉率、降低病历缺陷发生率,病历书写质量高,满意度高,组间差异有统计学意义(P<0.05)。结论病历书写质量可以防范医疗纠纷,降低纠纷率,差错率,投诉率,降低病历缺陷的发生率,并且可以提高满意度,具有临床应用价值。

Objective To analyze the role of medical record writing quality in preventing medical disputes.Methods From October 2019 to October 2020,132 patients were collected,randomly selected,and divided into two groups.The study group had 66 cases,which were managed by medical records,and the control group had 66 cases,which were not used for medical record management,and compare the disputes rate,error rate,complaint rate,medical record writing quality between the two groups,and evaluate the incidence of medical record defects and satisfaction in the two groups.Results Compared with the control group,the study group had low dispute rate,error rate,complaint rate,and low incidence of adverse events,high quality of medical record writing,and high satisfaction,the difference between the two groups was statistically significant(P<0.05).Conclusion The quality of medical record writing can prevent medical disputes,reduce the dispute rate,error rate,complaint rate,reduce the incidence of medical record defects,and improve satisfaction,which has clinical application value.