4758份急诊病历质量分析  

Quality Analysis on 4758 Emergency Medical Records

作　　者：王智巍[1] 

机构地区：[1]解放军第411医院急诊科,上海200081

出　　处：《解放军医院管理杂志》2011年第6期538-539,共2页Hospital Administration Journal of Chinese People's Liberation Army

摘　　要：目的检查急诊病案质量,找出存在的问题,总结经验,提高急诊医疗质量。方法随机抽检本院2008年6月至2010年5月急诊病历4 758份,对其内容进行分析。结果所检急诊病历存在字迹潦草,后续处置未注明时间未记录重要既往史等13个方面的问题。结论急诊病历不只是医疗文书,同时也是法律文书,遵循及时、真实、完整、准确的原则,以严谨的态度认真书写急诊病历。Objective To find out the blemish in the emergency cases and improve the treatment level by checking the quality of the emergency medical records.Method 4758 cases of emergency medical history were randomly checked during 2008.6-2010.5.In these medical histories,the content was analyzed,the defects were sought and classified,and the causes of these defects were discussed.Results There are 13 kinds of defects in the emergency cases.Conclusions The medical records of emergency cases are not only medical documents,but also legal documents.Every doctor should protect himself by the law,follow the rules timely,truly,roundly,exactly and perfectly,write the emergency cases seriously.

关 键 词：病历 急诊 质量管理 

分 类 号：R197.32[医药卫生—卫生事业管理]