死亡病历缺陷分析和评价  

Evaluation and Analysis of the Defects in Medical Records of the Death Cases

作　　者：王冠英[1] 路荣[1] 张珊红[1] 郑新瑞[2] 

机构地区：[1]第四军医大学西京医院 [2]第四军医大学研究生院

出　　处：《中国病案》2012年第9期23-25,共3页Chinese Medical Record

摘　　要：目的通过分析死亡病历书写缺陷,评价质量关键环节管控效果。方法对4年的死亡病历进行终末质量检查,应用PASW Statis-tics18软件进行统计分析。结果出院病历与死亡病历缺陷数卡方检验结果分别为χ2=99.498、χ2=64.328、χ2=64.565、χ2=47.690(P<0.01)。在病历缺陷评定无显著差异的情况下,死亡病历书写质量低于总体病历书写质量,OR=2.071,死亡病历包含出现缺陷的风险约是一般病历的2倍。出院病人甲级病案率与死亡率呈明显相关。结论提高病历质量是提高医疗质量和减少住院死亡率的有效措施。Objective To evaluate the quality of key links control effect by analyzing writing defects in medical records of the death eases. Methods Examine and analyze the end quality of medical records of death case in 4 years with applieation of PASW Statisticsl8 for statistical analysis. Results Two groups＇ chi-square test results were 99.498,64. 328,64. 565,47.690 （ P 〈 0.01 ）. In the ease of defect assessment showed no significant differ- enee, the death of medical records writing quality below the overall writing quality of medical records, OR = 2.071. Risk of defects in death records is about 2 times as the general medical records. The rate of A class medical records in discharged patient were significantly related to the death rates. Conclusion Improving the quality of medical records may be one of the effective ways to reduce the death rate and improve the quality of health care.

关 键 词：死亡病历 缺陷 质量分析 

分 类 号：R197.3[医药卫生—卫生事业管理]