病案中时间书写缺陷分析与对策  

Analysis on the Writing Defects of Time in Medical Records and Relevant Countermeasure

作　　者：阮鹤瑞[1] 郑荔[1] 胡华 苏晓津[3] 

机构地区：[1]新疆军区第23临床部,乌鲁木齐市830002 [2]解放军第12医院,喀什市844800 [3]兰州军区乌鲁木齐总医院干部病房,830011

出　　处：《中国病案》2015年第7期18-21,共4页Chinese Medical Record

摘　　要：目的促进病案书写质量,避免因时间书写缺陷导致医疗纠纷发生。方法随机抽取某医院2012年9月-2014年3月出院病案9369份,针对病案质控中病案时间书写的缺陷问题,依据原卫生部《病历书写基本规范(2010版)》和军区卫生部《病案质量检查评分标准细则》中病历书写时间要求,分析病案书写中时间缺陷的原因,并提出解决对策。结果随机抽取的出院病案9369份进行质控,其中时间书写合格病案8339份(占89%),存在时间书写缺陷的病案1030份(占11%);缺陷主要类型为书写时间前后倒错、日期时间记录不全、日期时间书写逻辑缺陷、时间记录不严谨等。究其原因是医务人员法律意识淡化、工作责任心缺失、素质不高、岗前培训不到位、护理人力资源不足等。结论病案中时间书写是病案质量管理的重要节点及法律凭证的客观依据,只有强化法律意识、加强岗前培训、提升临床基本素养、合理调配护理人员及重奖惩激发责任感等措施,激发医务人员提高书写病案质量的责任心,杜绝病案中时间书写缺陷的发生,有效避免医疗纠纷。Objectives To promote the development of the written quality of medical records and avoid the occurrence of medical disputes caused by writing defects of time. Methods 9369 cases of discharged medical records were randomly selected in a hospital from September 2012 to March 2014. Aimed at the defects problems existing in the written of time in the quality control of medical records, to conduct an analysis on reasons of time defects in the writing of medical records and propose countermeasures according to the time requirements of medical records writing in the ＂Basic Specification of Medical Records Writing （2010 version）＂ announced by the Former Ministry of Health as well as ＂The Score Standard Rules of Medical Records Quality Inspection＂ announced by the Health Ministry of the Military. Results To conduct quality control on the 9369 cases of discharged medical records, in which 8339 cases of medical records were qualified writing, which accounted for 89%, 1030 cases existing time writing defects, which accounted for 11%. The main types of defects included writing time perversion before and after, incomplete recording of date and time, logic defects of date and time writing as well as the inaccurate of time records. The reason may that the law awareness of the medical staff became weakened, lack of sense of responsibility, low quality, poor pre-job training and lack of nursing human resources. Conclusions The writing of time is an important node of medical records quality management and also the objective basis for legal evidence. We should only take measures such as strengthen legal awareness, enhance pre-job training, improve clinical basic quality, make a reasonable allocation of nurses and heavy incentives and other measures to stimulate the sense of responsibility of the medical staff, thus to prevent the occurrence of time writing defects in medical records and avoid medical disputes effectively.

关 键 词：病案质量 时间书写缺陷 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]