某军区死亡病历中的问题及建议  

Issues and Recommendations in the Quality Evaluation of Death Medical Records in a Military District

作　　者：李扬[1] 魏士清 

机构地区：[1]北京军区总医院质量管理科,北京市100700 [2]上海市第85医院,200052

出　　处：《中国病案》2013年第2期19-21,共3页Chinese Medical Record

摘　　要：目的全面掌握我区各医院基础医、护质量和为部队伤病员服务水平。方法将2010年10月1日-2012年3月31日的所有我区军人死亡病历按专业分布分给各位专家筛选出有较明显缺陷的病历。结果数据显示481例死亡病历中三级医师查房平均占61.66%,病历书写制度落实好的平均占56.3%,医院感染发生率平均为37.26%,主要疾病治疗方案合理充分平均占88.54%,发生压疮的患者平均比例为5.21%,在病历书写、核心制度、基础医疗质量和护理上均存在着不同程度的不足。结论将全区军人死亡病历质控工作列入常态管理,全面提升军区各医院的综合水平。Objective To have a comprehensive grasp of the basic medicine, nursing quality and the service level for the wounded troops in our district hospitals. Methods According to the distribution of profession, to classify all the military death medical records from October 1st, 2010 to March 31th 2012 in our district, and submit them to experts to check out obvious defects from these records. Results Among 481 death cases, the three level of ward round accounted for an average of 61.66%, with well practicable writing system of medical records take average of 56.3%, the incidence rate of nosocomial infection for an average of 37.26%, the main disease treatment scheme is reasonable and fully accounted for an average of 88.54%, the occurrence of pressure ulcers with an average ratio of 5.21%. There are various degrees of deficiencies in medical records writing, core system, the quality of nursing and basic medical treatment. Coadusion To enhance the comprehensive level of military hospitals, the quality control of military death medical records in the whole region is necessarily to be enrolled in the normal management of hospitals of the whole region.

关 键 词：死亡病历 质量评估 常态管理 

分 类 号：R821[医药卫生—临床医学]