病案中医嘱质量缺陷分析与管理对策  

Defects Analysis on the Quality of Medical Advices in Medical Records

作　　者：阮鹤瑞[1] 刘晓明[1] 刘海涛 王晓娟[1] 窦蕾 张晓英 

机构地区：[1]新疆军区23临床部,乌鲁木齐市830002 [2]乌鲁木齐市妇幼保健医院新生儿科,乌鲁木齐市830002 [3]新疆精神卫生中心,乌鲁木齐市830002

出　　处：《中国病案》2015年第1期21-23,共3页Chinese Medical Record

摘　　要：目的抽查出院电子病案医嘱处理过程常见的缺陷问题,分析原因、提出对策。方法通过医院医嘱系统,抽查部分归档前出院病案1936份,医嘱44529条。主要检查统计缺陷医嘱的类型。结果缺陷医嘱2245条,主要包括医嘱单下达医嘱医师与执行或校对护士漏手签名544频次(24.22%);医嘱单医师或护士签名潦草难以辨认299频次(13.32%);医嘱单书写或修改格式不规范206频次(9.18%)等16类医嘱缺陷。结论医嘱缺陷与医护人员法律观念淡化、能力素质不高、责任心缺失、质控不严密切相关。只有强化医护人员培训、加强法规意识、提高人员素质,规范医嘱流程与行为,才是提高医嘱书写质量,确保医护质量,维护医疗安全的重要保障。Objectives To conduct a random inspection on the common defects problems existing in the deal process of medical advices in discharged electronic medical records,analyze the reasons and put forward countermeasures.Methods 1936 cases of medical records discharged before archived and 44529 items were checked randomly through the medical advices system of the hospital,then conducted a statistical analysis on the types of medical advices defects.Results There were totally 2245 items of medical advices defects,which mainly included 16 types such as 544（24.22％）items were signatures missing of doctors or nurses while the carrying out or check up the medical advices; 299 （13.32％） items were signatures difficult to recognize and 206 （9.18％） items were unstandardized writing or modified mode of the medical advices.Conclusions The medical advices defects were closely related to the legal concepts fading of the medical staff,limited quality,missing responsibility and loose quality control.Only by enhancing the health care training,strengthening regulatory awareness,improving the quality of personnel as well as standardizing the process and behaviors of doctor advices,could we improve the quality of writing and ensure the quality of medical care,and protect the security of medical treatment.

关 键 词：医嘱质量 缺陷 管理对策 

分 类 号：R197.323[医药卫生—卫生事业管理]