死亡病案抢救记录缺陷与防范  

Investigation and Prevention of Rescure Records Defects in Death Documents

作　　者：程新[1] 楼婷[1] 王颖莹[1] 

机构地区：[1]解放军总医院南楼住院病案管理科,北京市100853

出　　处：《中国病案》2016年第6期16-18,共3页Chinese Medical Record

摘　　要：目的通过分析死亡病案医疗护理抢救记录,提高病案书写质量和减少缺陷,降低医疗安全风险。方法分析某院2014年5月-2015年5月共194份死亡病案医疗护理抢救记录,就抢救过程、生命体征的描述、医护记录情况等三个关键点进行分析。结果 194份病案共检出缺陷514处,抢救过程中书写记录不规范244例,占比47.47%,其中抢救人员姓名及职称、抢救起始时间、抢救药物剂量、浓度漏记最为严重;生命体征记录不全232例,占比45.14%;医护记录不一致38例,占比7.39%。结论死亡病案抢救记录缺陷较多,需加强培训和质控,规避安全风险。Objective We analyzed the rescue records of medical documents for dead patients, to improve the quality of medical documents by skillful writing, thus avoiding risks. Methods A total of 194 rescue records of medical documents for dead geriatric patients in our hospital from May 2014 to May 2015 were analyzed with 3 important aspects, including the depiction of rescue process, vital signs narrating, and comparison between medical and nursing records. Results 514 defects were revealed in 194 medical records. Among them, 244 defects（47.47%） happened in rescue process depiction, especially neglecting the name and title of staff, onset and end time, dose and concentration of rescue drugs. 232 defects（45.14%） happened in vital signs narrating. 38 inconsistency（7.39%） between medical and nursing records were also verified. Conclusions Considering the amount of defects found in rescue medical records, the training courses of writing skills and quality control for doctors and nurses should be taken regularly to avoid risks.

关 键 词：死亡病案 抢救记录 质量缺陷 医护一致性 

分 类 号：R197.323[医药卫生—卫生事业管理]