某院2010年终末病案检查结果分析  

An Analysis on Final Medical Records Examination Results of a Hospital in 2010

作　　者：李凌[1] 钟帆[1] 黄美筠[1] 杜惠芳[1] 

机构地区：[1]广州市第一人民医院,广州市510180

出　　处：《中国病案》2011年第9期15-16,共2页Chinese Medical Record

摘　　要：目的寻找终末病案缺陷原因以改进病案质量。方法对照《广东省病历书写与管理规范》及我院病历书写规范对5688份终末病案进行质量检查,分析各类缺陷。结果甲级病案5332份;乙级病案334份;丙级病案22份。病案首页3项未填写是造成缺陷病案的最主要原因,外科的缺陷病案最多,为181份。结论继续加强教育、增强医师的责任心是改变目前病案质量的必要手段。Objectives To find out the defect reasons of final medical records for improving quality of medical records.Methods According to Writing and Management Regulations and Rules of Medical Records in Guangdong Province and writing regulations and rules of medical records in our hospital,we had quality examination on 5688 final medical records analyzing all kinds of defects.Results There are 5332 grade A medical records;334 grade B medical records and 22 grade C medical records.The most major reason causing defect is infilling 3 items in front page of medical records,in which the defect medical records in surgery are 181 that are the most.Conclusion The necessary methods to change the current medical records quality are to continually strengthen education and responsibility of doctors.

关 键 词：病案质量 分析 

分 类 号：R197.3[医药卫生—卫生事业管理]