重庆市乡镇卫生院病案书写质量调查  

A Survey of Medical Record Writing Quality of Township Hospitals in Chongqing

作　　者：郑洁[1] 杨庆军[1] 吴世友[1] 唐贵立 何永宏 

机构地区：[1]重庆市中山医院,重庆市400013 [2]重庆市卫生局,重庆市401147 [3]重庆市医科大学附属一院,重庆市400016

出　　处：《中国病案》2012年第4期23-24,共2页Chinese Medical Record

摘　　要：目的加强和规范乡镇(中心)卫生院病案书写质量,提高医疗技术水平。方法随机抽查34所乡镇(中心)卫生院出院病案共340份,按2010年卫生部《病历书写基本规范》内容对照检查。结果病案书写缺陷率较高,其中病程记录缺陷率达63.53%、手术记录缺陷率40.88%。结论应加强乡镇(中心)卫生院院、科、室三级病案质量管理体系建设,提高病历书写质量管理,确保医疗安全和医疗质量。Objective To strengthen and standardize the quality of writing of the township hospitals medical records and raise the level of medical technology.Methods A random check of 340medical records from 34 towns（central） hospitals and the records were checked according to the basic norms of medical records of 2010.Results There is a higher defect rate of medical record writing and the defect rate of progress notes is 65.53% and the defect rate of operation records is 40.88%.Conclusion The construction of record quality management system of hospital,scientific and room should strengthened,the quality of records＇ writing should be improved,and to ensure medical safety and quality of care.

关 键 词：乡镇卫生院 病案书写 调查 

分 类 号：R197.6[医药卫生—卫生事业管理]