门诊病历书写质量的统计分析

Statistical analysis of the quality of medical records in outpatient service

目的 :了解门诊病历书写规范化状况 ,分析影响门诊病历书写质量的主要因素 .方法 :依据门诊病历书写质量评价标准 ,对 2 0 0 0 0 7/2 0 0 0 10我院门诊 19个临床科室就诊患者的病历进行随机抽查评定 ,应用SPLM软件进行统计分析 .结果 :730份病历中 ,甲级病历 (评分≥ 85分 ) 6 85份(93.84 % ) ,平均得分 94 .6 3;科室要求严格、技术职称较高、熟悉病历书写规则的医师 ,病历书写质量较高 .结论 :提高病历书写质量应重点加强对初级医生和进修医生的培养训练 .

AIM: To evaluate the present situation of medical records in our outpatient service and to analyze the major factors influencing the quality of medical records in our outpatient service. METHODS: According to the standards of evaluating the quality of medical records in outpatient service, random sampling was made among 19 clinical departments of Xijing Hospital from July to October in the year of 2000. And the software SPLM was applied for the statistical analysis. RESULTS: 685 medical records out of the 730 ones were evaluated as the first rate (the score was no less than 85 points), with an average of 94.63. The well written medical records were written by senior doctors with higher professional titles, who were familiar with the rules of writing medical records and whose department set strict demands on them. CONCLUSIONS: To improve the quality of medical records in outpatient service, junior doctors and doctors here for further training should have specific training in writing medical records.