医护共同参与提高住院病案记录一致性调查  

The effect of mutual participation model on improving consistency of medical records

作　　者：任伶俐[1] 

机构地区：[1]川北医学院附属医院内分泌科, 南充637000

出　　处：《中华现代护理杂志》2010年第15期1834-1835,共2页Chinese Journal of Modern Nursing

摘　　要：目的强调医护共同参与，提高医护记录一致性。方法回顾性分析2008年230份住院病案中医护记录不一致情况，针对存在的问题，医护共同参与住院病案质量管理，与质控后（2009年）住院病案进行检查对比分析。结果2009年住院病案医护记录不一致明显减少，与2008年比较，差异有统计学意义。结论医护共同参与能有效提高住院病案医护记录的一致性。Objective To explore the effect of mutual participation model on improving consistency of medical records. Methods A total of 230 cases of medical records in 2008 were retrospectively analyzed. Based on the existing problems, medical staffs participated jointly in medical records management. The quality of medical records in 2009 was compared with 2008. Results The inconsistency phenomenon in medical records in 2009 decreased significantly. Conclusions Mutual participation model can improve consistency of medical records.

关 键 词：医护共同参与 医护记录 一致性 

分 类 号：R197.323.1[医药卫生—卫生事业管理]