4325例病案检查结果分析  

Analysis Check Result of 4325 Case Medical Records

作　　者：贾燕 蒋亚平 JIA Yan,JIANG Ya-ping （Xinhua Hospital of Xinhua Community Health Service Center, Xinhua Street, Huadu District, Guangzhou 510800,China）

机构地区：[1]广州市花都区新华街新华社区卫生服务中心新华医院,广东广州510800

出　　处：《医学信息》2010年第16期2657-2659,共3页Journal of Medical Information

摘　　要：检查上半年住院病的案书写质量,找出影响病案质量的主要因素,寻求提高病案质量的最佳方法。选取上半年（2009年1月至6月）的出院病案4325份,对照广东省《病例书写与基本规范》进行评价。随着医疗科学的发展,人民群众的自我保健意识不断增强,医院住院病人逐渐增多。病案记录的规范、完整、详细、准确对住院病人诊治预后判断及国际疾病分类具有重要意义,也是处理医疗纠纷的法律凭证。我院按《病历书写规范》[1],对2009年1-6月的出院病历进行抽查,以便尽早发现问题,及时纠正,减少医疗纠纷发生的隐患。To examine the writing quality of inpatient medical records in first half year, find out the main factor that affects it and seek for the best method to improve it. We select 4,325 cases of medical records discharging from hospital in first half year （from January 2009 to June 2009） and evaluate them contrasting with Medical Writing and Basic Norms of Guangdong province, and get the results after discussing.With the development of medical science, people＇s growing awareness of self -care has continually enhanced so that there is a gradual increase in hospital inpatient. The specifications, completion, details, accuracy of medical record files are not only crucial for inpatient＇s diagnosis, treatment of post-judgment as well as the classification of international diseases, and it is also the legal certificate for dealing with the medical tangle. In accordance with Medical Writing Norms, the medical records from Jan. to June in 2009 were carried out spot check in our hospital, so that we can find problems out by return, correct them punctually and reduce the risks of the occurrence of medical disputes.

关 键 词：病案质量 缺陷 对策 

分 类 号：R574.62[医药卫生—消化系统;医药卫生—临床医学;医药卫生—内科学]