某院首次病程记录书写质量分析

Analysis on the Writing Quality of the First Medical Record in a Certain Hospital

目的通过分析某院首次病程记录中存在的缺陷,探讨整改路径,切实提高病案的内涵质量。方法按照原国家卫生部发布的病历书写基本规范中对首次病程记录的要求,对某院2023年10月1日-11月30日期间共计2524份内科与外科出院病案展开调查,针对首次病程记录存在的缺陷问题进行描述性统计分析。结果住院病案首次病程记录总平均分为(87.35±2.63)分;外科科室首次病程记录平均分为(82.54±2.14)分,内科科室平均分为(91.81±2.76)分;683份病案首次病程存在缺陷,占所有病案的27.06%。首次病程缺陷按类别分为9项,各项的缺陷问题共计733例,其中诊断依据不充分占18.83%,病例特点缺乏归纳提炼占14.05%,诊疗计划有遗漏占13.37%。结论病案首次病程记录存在一定的缺陷,应加强病历书写系统性培训,增强医疗纠纷的防范意识,创新病案质控模式,以有效提升首次病程记录的质量,提高医院的病案管理水平。

Objectives By analyzing the defects in the first medical record of a certain hospital,this study aims to explore the rectification path and effectively improve the connotation and quality of medical records.Methods According to the requirements of the"Basic Norms for Medical Record Writing"issued by the former Ministry of Health,a total of 2,524 discharged medical records from a certain hospital or surgery from October 1 to November 30,2023 were investigated.Descriptive statistical analysis was conducted on the defective initial records.Results The total average score of the first medical record of the inpatient medical record was(87.35±2.63 points);the average score of the first medical record of the surgical department was(82.54±2.14 points),and the average score of the first medical record of the internal medicine department was(91.81±2.76 points).683 medical records had defects in the first course of illness,accounting for 27.06%of all medical records.The first course defects were divided into 9 categories,with a total of 733 cases of defects in each category.Among them,18.83%of the cases had insufficient diagnostic basis,14.05%of the cases had lack of summary and refinement of case characteristics,and 13.37%of the cases had omissions in the diagnosis and treatment plan.Conclusions There are certain deficiencies in the first stage of medical records.Hospitals should strengthen systematic training on medical record writing,enhance awareness of preventing medical disputes,and innovate medical record quality control models to effectively improve the quality of the first medical record,improve the hospital's medical record management level.