门急诊病历书写质量案例分析  

Cases Analysis on Outpatient and Emergency Medical Records Writing Quality

作　　者：周季兰[1] 包清[1] 

机构地区：[1]上海交通大学医学院附属新华医院门急诊办公室,上海市200092

出　　处：《中国病案》2012年第5期16-17,共2页Chinese Medical Record

摘　　要：叙述门急诊4例医疗纠纷,分析其与病历书写不规范之间的关系和产生门急诊病历缺陷的主客观原因,探讨提高门急诊病历质量的可行性方法,重视岗前培训,合理安排临床医师,加强质量监督管理,注重整改落实,从而防范医疗风险,促进门急诊工作的可持续发展。This article elaborates four medical tangles in outpatient and emergency and analyzes the relationship between them and non-standard medical records writing,further analyzing the object and subject reasons of defects medical records of outpatient and emergency.It discusses practical methods of improving quality of outpatient and emergency medical records that are value of pre-job training,reasonable arrangement of clinical doctor,quality supervision management of outpatient and emergency medical records strengthening,quality control and feedback improvement,value on rectify and reform and continual improvement.Therefore,it prevents medical risk and improving sustainable development of outpatient and emergency work.

关 键 词：门急诊 医疗纠纷 病历质量 

分 类 号：R197.3[医药卫生—卫生事业管理]