7所医院440份病历书写质量分析.doc

文档介绍：7所医院440份病历书写质量分析
(作者:___________单位: ___________邮编: ___________)
作者:孙学军,安红军,徐金江,于麦生
【摘要】目的分析病历书写中存在的问题,为提高病历书写质量提供依据。方法随机抽查7所医院中的440份病历,按有关标准、规定逐项检查评分。结果总评甲级病案率为925%,乙级病案为75%,无丙级病历。外科系统甲级病历占914%,内科占936%。死亡病历中甲级病历占878%,出院病历中甲级病历占971%。结论端正态度,加强责任心是保证病历质量的关键因素。
【关键词】病历;质量控制
Analysis on Quality of 440 Medical Records from Seven Hospitals
Abstract: Objective To analyze the problems in medical record writing so as to provide facts for the improvement in medical record writing’s quality. Methods From seven hospitals, 440 medical records were drawn out at random, and then were checked item by item according to relevant criteria. Results Among the 440 medical records, % belonged to grade A, % to grade B, and none to grade rate of grade A was % in surgical system and % in internal medicine system. Among the death medical records, the rate of grade A accounted for %, while it was % in leaving-hospital records. Conclusion It is the key to the improvement i
n medical record quality to take up a proper attitude or strengthen responsibility.
Key words: medical record; quality control
病历是反应疾病发生、发展、诊治过程及病情转归的重要医疗文件,也是反映临床医师应用医学基本知识、基本理论、基本技能的客观依据;同时病历还是教学、科研的基本资料和法律文书。笔者参加7所医院2004年医护质量检查,抽查了440份病历进行质量评审,现将存在的主要问题及其发生的原因分析报告如下。
1 资料与方法
11 资料来源
病历来源于7所中心或驻军医院2004年的病历,采用随机的方法每所医院抽查出院病历40份(其中死亡病历20份)内外科系统各半,在院病历160份进行环节质量检查,共计440份。
评审依据