我院急诊病历书写质量分析  

Quality analysis of emergency medical records in our hospital

作　　者：包卫华[1] 

机构地区：[1]解放军第二五三医院质控办,内蒙古呼和浩特010051

出　　处：《中国当代医药》2013年第16期179-180,共2页China Modern Medicine

摘　　要：目的总结分析本院急诊病历书写质量,针对问题缺陷提出管理对策,确保临床医疗安全。方法抽检本院2011年6月～2012年12月1872份急诊病历,对书写质量问题及缺陷进行统计分析。结果急诊病历书写质量不乐观,1872份急诊病历存在相关质量问题缺陷3189条。结论急诊病历是医院诊断、抢救、处置水平的综合体现,也是规避医疗风险的重要一环,医院各级管理人员应重视急诊病历质量管理,加强法律教育及专业理论及技能的培训,不断提高责任意识及书写急诊病历水平。Objective To guarantee clinical care safety, evaluate and summarize the quality of the emergency medical records in our hospital, and put forward management strategy according to the defects in records. Methods Statistic analysis of these defects was based on spot check of 1872 emergency medical records between June 2011 to December 2012. Results Writing quality of these emergency medical records was not optimistic. 3189 defects were existed in the 1872 emergency medical records. Conclusion Emergency medical record is a comprehensive reflection of our hospital＇s level of diagnosis, rescue and treatment; also it is an important link of avoiding medical risks. Therefore, every manager in the hospital should attach importance to the quality management of emergency medical record, and enforce law education and train of specialized theory and skills to constantly increase responsibility conscientiousness and writing level of emergency medical record.

关 键 词：急诊病历 质量管理 医疗安全 分析 

分 类 号：R197.3[医药卫生—卫生事业管理]