死亡病历书写质量缺陷分析与对策  

Defects Analysis and Countermeasures of Death Medical Record Writing Quality

作　　者：阮鹤瑞[1] 刘海涛 刘江玲 胡华 张艳玲 傅凯丽[4] 

机构地区：[1]新疆军区第23临床部,乌鲁木齐市830002 [2]新疆精神卫生中心,乌鲁木齐市830002 [3]解放军第12医院,喀什市844800 [4]新疆军区联勤部卫生处,乌鲁木齐市830002

出　　处：《中国病案》2015年第8期16-19,共4页Chinese Medical Record

摘　　要：目的通过分析死亡病历书写存在的质量缺陷,寻求解决提升病历书写质量的措施。方法抽查某医院2010年1月1日至2014年12月31日死亡病案137份,对存在质量缺陷回顾性分析。结果 137份死亡病案中检出缺陷病案69份(50.36%),其中各科室缺陷死亡病案分布:内科23例(33.34%)、感染科22例(31.88%)、肿瘤科12例(17.39%)、外科10例(14.49%)、精神科2例(2.90%);共检出缺陷项目20项,缺陷达291频次。结论医院应定期加强医务人员法律与技能培训、历练临床基本功、落实病例讨论制度、加强医护沟通确保内涵质量、实行奖惩责任追究等措施来控制与提升死亡病案质量。Objective To analyze quality defects of death medical records, and seek measures to enhance the quality of writing. Methods 137 death medical records from January 1,2010 to December 31,2014 were retrospectively analyzed. Results 69 medical records have defects（50.36%）, of which the death of the departments in order： Medicine 26 cases（37.68%）, infections department 25（36.23%）, oncology department 12 cases（17.39%）, surgical department 10 cases（14.49%）, department of psychiatry two cases（2.90%）; 20 projects were found defects, defect frequencies up to 291 times. Conclusion Hospital medical staff should strengthen the legal and regular skills training, encourage clinical practice basic skill, implement case discussion system,strengthen communication to ensure the quality of the connotation, accountability incentives and other measures to control and improve the quality of medical records of death.

关 键 词：死亡病案 质量缺陷 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]