死亡病案质量监控与缺陷分析  

Supervision and analysis on defect and quality of death medical record

作　　者：陈丽娟[1] 

机构地区：[1]广东医学院附属医院病案室,广东湛江524001

出　　处：《吉林医学》2014年第8期1653-1655,共3页Jilin Medical Journal

基　　金：广东省湛江市科技攻关项目[项目编号:2012C3101037]

摘　　要：目的:通过分析死亡病案书写质量缺陷及原因以提高死亡病历书写质量。方法:选用2011年死亡病案494份,回顾性分析出现缺陷的项目和原因。结果:影响死亡病案书写质量的主要项目包括漏填、填写不符合标准、涂改、记录不准确、签改不及时。缺陷项目主要在病案首页填写、入院记录、首次病程记录、病程记录、护理文书等方面,其中,病程记录缺陷项目主要以反映死亡病案的抢救记录、死亡记录、死亡原因书写缺陷为主。结论:严格监控影响死亡病历书写质量的主要原因,努力提高死亡病案的书写质量。Objective The purpose of this study is to improve the writing quality by analyzing the quality defe e the quality defect projects and reasons by retrospective survey.Results The main reasons of affecting death medical record writing quality were fill drain,fill out non-compliant,alter,record inaccurate,not timely signature.The major defect projects including medical record,hospital records,the first progress notes,progress notes,nursing instruments.The defect in the course of history was mainly rescue records,death records,cause of death.Conclusion In order to improve the writing quality of the death medical record,it is should be strictly monitoring the defect projects and reasons in death medical record.

关 键 词：死亡 病案 质量 监控 缺陷 分析 

分 类 号：R197.323.1[医药卫生—卫生事业管理]