病情评估记录质量分析  

Quality Analysis on the Records of Medical Condition Assessment

作　　者：韩轶超[1] 杨秀芳[1] 谢娜[1] 郑文选[1] 张秀岩[1] 彭晔[1] 

机构地区：[1]哈励逊国际和平医院,衡水市053000

出　　处：《中国病案》2016年第3期19-21,共3页Chinese Medical Record

摘　　要：目的加强病情评估,提高诊疗水平及病案书写质量,确保医疗质量和患者安全。方法随机抽取某院2015年1月500份包含手术或介入诊疗的出院病案,对病情评估相关内容进行专项质控,将质控结果录入Excel表中进行统计分析。结果 500份病案中145份存在缺陷,缺陷率29%。缺陷共234项次,较常见缺陷依次为:出院前病程无病情评估占9.6%;术后三天内无病情评估占8%;未根据评估结果做相应的告知占7%;术前无病情评估占6.4%;评估内容不全面或不到位占5.6%。结论病情评估专题培训有利于加强医疗风险防范意识,提高专业技术水平,确保评估的准确性及治疗的及时性,有效降低医疗风险,减少医疗事故发生。Objective To strengthen medical condition assessment, improve the level of medical diagnosis and treatment as well as quality of medical records, and ensure medical quality and patient safety. Methods 500 copies which included surgical or interventional diagnosis and treatment of archiving medical records were randomly selected from a hospital in January 2015. To conduct quality control on the content related with medical condition assessment and make statistical analysis on the results of quality control with Excel table. Results There were 145 cases of medical records existing defects in all of the 500 cases, and the defect rate was 29%. The total number of defects was 234 items, and the common defects were as follows ： no condition assessment before discharge （9.6%）, after surgery within three days no condition assessment （8%）, no informed accordingly based on the assessment results （7%）, lacking of preoperative evaluation （6. 4%）, no comprehensive assessment or no in place （5.6%）. Conclusions To conduct special training on medical condition assessment theme is beneficial to strengthen risk awareness, improve professional skills, ensure the accuracy of the condition assessment and timeliness of treatment, reduce the medical risks and the occurrence of medical accidents effectively.

关 键 词：病情评估 质量分析 对策 

分 类 号：R197.323[医药卫生—卫生事业管理]