终末病案出院记录缺陷分析与改进对策  

Defect Analysis and Improvement Measures of Terminal Medical Records Discharge Records

作　　者：刘晓明[1] 阮鹤瑞[1] 

机构地区：[1]新疆军区第23临床部,乌鲁木齐市830002

出　　处：《中国病案》2015年第8期21-24,共4页Chinese Medical Record

摘　　要：目的针对性对出院记录书写存在的缺陷问题进行分析,寻找改进对策。方法依据原卫生部颁布的《病历书写基本规范(2010年版)》与军区卫生部《病案质量检查评分细则》,对某医院2012年6月1日至2014年5月31日出院归档前的终末病案9936份,针对病案中出院记录质量进行质控检查统计,共检出出院记录存在缺陷936份(占9.43%),将出院记录按照患者一般信息、入院基本情况、诊疗经过、主要辅助检查结果、病理诊断、出院情况、出院主要诊断、出院医嘱、医师签名等内容,逐项质控检查进行分析统计。结果 936份出院记录存在质量缺陷,按出院记录存在缺陷项目统计依次为重要辅助检查结果漏记109份(占11.66%);诊疗经过不具体106份(11.35%);出院医嘱内容不全103份(11.07%)等16项。结论加强临床医师岗前培训、强化法律意识与责任心、加强临床基本素养的历练、落实三级医师负责制、奖惩并举激发质量意识等措施,对提高病案质量管理与病历书写质量具有重要意义。Objective To analyze the defects in discharge records, and find improvement measures. Methods Checking 9936 copies of terminal medical records from June 1st, 2012 to May 31, 2014 based on the former Ministry of Health issued the ＂medical writing basic specification（2010 edition）＂ and the Military Health Department ＂record quality checks scoring rules＂. There are 936 discharge records existing flaw, accounted for 9.43%. Results Checking and analyzing patients basic information, Basic situation in hospital, Diagnosis and treatment, the main ancillary diagnostic test results, the pathological diagnosis, discharge conditions, the main discharge diagnosis, doctor＇s advice, physician signature, etc. 936 discharge records exist quality defects. The Defect project statistics were, in order, important ancillary diagnostic results omission 109（11.66%）; no specific Diagnosis and treatment 106（11.35%）; Discharge Instructions content incomplete 103（11.07%） and other 16 items. Conclusion The methods of strengthen pre-service training, strengthen legal awareness and sense of responsibility, strengthen basic knowledge of clinical experience, the physician in charge of the implementation of three system, incentives and other measures to stimulate the sense of quality have important significances for improving the quality of medical record management and medical record writing quality.

关 键 词：病案质量 出院记录 缺陷分析 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]