感染性疾病科缺陷病案的分析与措施  

Analyze and take steps to the defective medical records of infection department

作　　者：谢俊强[1] 陈敏[1] 

机构地区：[1]中山大学附属第三医院,510630

出　　处：《内蒙古中医药》2012年第12期58-59,共2页Inner Mongolia Journal of Traditional Chinese Medicine

摘　　要：目的:分析感染性疾病科2010年终末质控病历书写质量的情况。方法:按照《广东省病历书写与管理规范》和自制《中山三院终末病历评分表》对感染性疾病科422份病案进行终末质控,并对缺陷项目进行统计分析。结果:抽查病历422份,病历缺陷共1562项次,缺陷最多的病案是知情同意书445次,占总缺陷28.49%,其次是病程记录的缺陷431次,占总缺陷的27.59%。结论:加强临床医师的法制观念和责任心,加强岗前培训,加强环节病历和终末病历质量控制,确保病案书写质量。Objective：Analyze the terminal quality of medical records of infection department in 2010. Methods： According to the （（Medical records writing and management standard of Guangdong Province））and home made （（final medical record score sheet of the No 3 Hospital Affiliated to Zhongshan University））, 422 medical records of infeetion department were exercised final quality control, and the results were analyzed.Results： 1562 defects were found, mostly in the informed consent form and seeondly in medical and treatment records, aecounting for 28.49% （445/1562） and 27.59% （431/1562） respectively. Conelusion： We should strengthen the concept of law and the sense of respansibility,pre-job training of the physieians. At the same time, we should enhance the link quality control and final quality control to improve the quality of medical reeord.

关 键 词：病案 缺陷 分析 措施 

分 类 号：R197.323[医药卫生—卫生事业管理]