医院病案终末质量现状分析和对策  

An Analysis of the State quo of the End Quality of the Medic al Records and the Countermeasures

作　　者：易田[1] 陈梅燕[1] 罗静云 吕秀娟[1] 

机构地区：[1]广东省深圳市宝安区人民医院病案科,深圳市518101

出　　处：《中国病案》2006年第9期13-15,共3页Chinese Medical Record

摘　　要：目的为了进一步提高住院病历书写水平,确保医疗质量和医疗安全的稳步上升,探讨我院病历书写存在问题,提出改进措施。方法通过单项筛选法和终末质量评分法相结合,对我院2005年出院病案,实施全面的终末质量监控。结果在17241份病案中有1570份存在不同程度缺陷,其中乙级病案95份、丙级病案17份。结论提高病案质量的重点在于强化全院医务人员的法律意识,重视病历书写。To explore the problem of the medical records （MRs） in documentation and improve the quality of the medical record and ensure the quality and safe of the Medical treatments. And then advanced the measures of improvement. Method Combining the single item screening method with the end quality score method, we inspected and monitored the end quality of the MRs in 2005 year and enforced monitoring all around. Result Among the 17241 MRs, 1570 of them have different defects including 95 of the second degree and 17 of the third degree. Conclusion The emphasis of increasing the MRs quality is lied in strengthening the law consciousness of the whole medical members, who should think highly of the documentation of MR.

关 键 词：病案质量 问题分析 对策 

分 类 号：R197.3[医药卫生—卫生事业管理]